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Tariq R, Siddiqui UA, Bajwa MH, Baig AN, Khan SA, Tariq A, Bakhshi SK. Feasibility of awake craniotomy for brain arteriovenous malformations: A scoping review. World Neurosurg X 2024; 22:100321. [PMID: 38440377 PMCID: PMC10911851 DOI: 10.1016/j.wnsx.2024.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Background Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Current treatment protocols include stereotactic radiosurgery, transarterial embolization, and surgical resection under general anesthesia. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes. Objectives We reviewed the current literature reporting surgical outcomes and assessed the feasibility of AC for AVM resection. Methods The PRISMA guidelines were utilized as a template for the review. Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed. Results 12 studies were included with a total of 122 AVM cases. Spetzler-Martin grading was used for the classification of the AVMs. The asleep-awake-asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n = 2) and bleeding (n = 4). Short-term post-operative complications included hemorrhage (n = 3), neurologic dysfunctions including paresis (n = 3), hemiplegia (n = 10), dysphasia/aphasia (n = 6), cranial nerve dysfunction (n = 3), and pulmonary embolism (n = 1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups. Conclusion AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas as mapping during AC identifies the eloquent cortex thus promoting careful tissue handling which may preserve neurologic function and/or predict the postoperative functional status of the patients We, therefore, conclude that AC is a viable modality for AVMs resection near eloquent language and motor areas.
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Affiliation(s)
- Rabeet Tariq
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | | | - Ahmer Nasir Baig
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Saad Akhtar Khan
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Areeba Tariq
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Saqib Kamran Bakhshi
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
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Shahbandi A, Sattari SA, Haghshomar M, Shab-Bidar S, Lawton MT. Application of diffusion tensor-based tractography in treatment of brain arteriovenous malformations: a systematic review. Neurosurg Rev 2023; 46:115. [PMID: 37162690 DOI: 10.1007/s10143-023-02017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/11/2023]
Abstract
There is no systematic review investigating the utility of Diffusion tensor-based tractography findings for treating brain arteriovenous malformations (bAVMs). This systematic review aims to investigate the outcomes following bAVM treatment when tractography data is incorporated into treatment planning. PubMed/MEDLINE, Scopus, and Cochrane Library, were searched for published studies. Prospective or retrospective studies involving at least one patient with confirmed bAVM and available data on tractography and clinical outcomes were included. A total of 16 studies were eligible for this review, consisting of 298 patients. 48.2% of patients were female. The mean age of the patients was 27.5 years (range: 5-77). Stereotactic radiosurgery (SRS) and microsurgical resection each were the treatment of choice in eight studies, respectively. Two-hundred forty-eight patients underwent SRS as the primary treatment, while microsurgery was used to resect the bAVMs in 50 patients. The corticospinal tract, optic pathway, and arcuate fasciculus were the most widely investigated white matter tracts. Tractography disruption and failure frequencies were 19.1% and 1.8%, respectively. The pooled proportions (95% CI) of obliteration rates were 88.78% (73.51-95.76) for microsurgery and 51.45% (13-17-88.10) following SRS. Treatment-related non-hemorrhagic complications rates occurred in 24.2% and 9.9% of patients who underwent microsurgical resection and SRS, respectively. Tractography findings can contribute to providing a more accurate dosimetry analysis of functional white matter tracts at risk prior to SRS and minimizing the surgical morbidity following microsurgical resection.
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Affiliation(s)
- Ataollah Shahbandi
- School of Medicine, Tehran University of Medical Sciences, Enghelab Street, Tehran, Iran
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA.
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3
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Thomas JM, Sasankan D, Abraham M, Surendran S, Kartha CC, Rajavelu A. DNA methylation signatures on vascular differentiation genes are aberrant in vessels of human cerebral arteriovenous malformation nidus. Clin Epigenetics 2022; 14:127. [PMID: 36229855 PMCID: PMC9563124 DOI: 10.1186/s13148-022-01346-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 10/02/2022] [Indexed: 12/04/2022] Open
Abstract
Arteriovenous malformation (AVM) is a tangle of arteries and veins, rupture of which can result in catastrophic hemorrhage in vulnerable sites such as the brain. Cerebral AVM is associated with a high mortality rate in humans. The causative factor or the stimulus at the artery-venous junction and the molecular basis of the development and progression of cerebral AVM remain unknown. While it is known that aberrant hemodynamic forces in the artery-vein junction contribute to the development of AVMs, the mechanistic pathways are unclear. Given that various environmental stimuli modulate epigenetic modifications on the chromatin of cells, we speculated that misregulated DNA methylome could lead to cerebral AVM development. To identify the aberrant epigenetic signatures, we used AVM nidus tissues and analyzed the global DNA methylome using the Infinium DNA methylome array. We observed significant alterations of DNA methylation in the genes associated with the vascular developmental pathway. Further, we validated the DNA hypermethylation by DNA bisulfite sequencing analysis of selected genes from human cerebral AVM nidus. Taken together, we provide the first experimental evidence for aberrant epigenetic signatures on the genes of vascular development pathway, in human cerebral AVM nidus.
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Affiliation(s)
- Jaya Mary Thomas
- Cardio Vascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Poojappura, Thycaud, Thiruvananthapuram, Kerala, India, 695014
| | - Dhakshmi Sasankan
- Department of Biotechnology, Bhupat and Jyoti Mehta School of Biosciences, Indian Institute of Technology, Madras, Chennai, Tamil Nadu, 600036, India
| | - Mathew Abraham
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India, 695011
| | - Sumi Surendran
- Cardio Vascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Poojappura, Thycaud, Thiruvananthapuram, Kerala, India, 695014
| | - Chandrasekharan C Kartha
- Department of Neurology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, 682041, Kerala, India.
| | - Arumugam Rajavelu
- Department of Biotechnology, Bhupat and Jyoti Mehta School of Biosciences, Indian Institute of Technology, Madras, Chennai, Tamil Nadu, 600036, India.
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Vaz MAS, Monteiro JM, Tzu WH, Neto MR, Holanda VD, Figueiredo EG, Isolan GR. Professor Evandro de Oliveira, a guiding light in skull base surgery and vascular neurosurgery. Surg Neurol Int 2022; 13:229. [PMID: 35855122 PMCID: PMC9282787 DOI: 10.25259/sni_75_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - Jander Moreira Monteiro
- Department of Neurosurgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul,
| | - Wen Hung Tzu
- Department of Neurosurgery, University of São Paulo, Faculdade das Clinicas,
| | - Mateus Reghin Neto
- Department of Microsurgical Laboratory, Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | - Vanessa de Holanda
- Department of Microsurgical Laboratory, Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | | | - Gustavo Rassier Isolan
- Department of Neurosurgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul,
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Surgical Management of Cranial and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Brain Arteriovenous Malformations Classifications: A Surgical Point of View. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:101-106. [PMID: 33973036 DOI: 10.1007/978-3-030-63453-7_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Brain arteriovenous malformations (AVMs) classification has been the subject of extensive discussion. The aim of our work was to review the main classification schemes proposed in the literature, which can be summarized in four main groups: (a) traditional schemes oriented to evaluate the operability of AVMs have been joined by (b) specific classifications that evaluate the outcome and the predictability of obliteration of other treatment modalities and (c) others that evaluate the outcome of intracerebral hemorrhages in ruptured AVMs. Eventually, (d) topographical classifications that categorize the subtypes of AVMs located in specific anatomical regions have been drawn. For each classification, we discuss the implications on surgical management.
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Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
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Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Baharvahdat H, Blanc R, Fahed R, Pooyan A, Mowla A, Escalard S, Delvoye F, Desilles JP, Redjem H, Ciccio G, Smajda S, Hamdani M, Mazighi M, Piotin M. Endovascular treatment as the main approach for Spetzler-Martin grade III brain arteriovenous malformations. J Neurointerv Surg 2020; 13:241-246. [PMID: 32989031 DOI: 10.1136/neurintsurg-2020-016450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Because Spetzler-Martin (SM) grade III brain arteriovenous malformations (bAVMs) constitute a heterogeneous group of lesions with various combination of sizes, eloquence, and venous drainage patterns, their management is usually challenging. The aim of this study is to evaluate the clinical/imaging outcomes and the procedural safety of endovascular approach as the main treatment for the cure of SM grade III bAVMs. METHODS In this retrospective study, prospectively collected data of SM grade III bAVMs treated by endovascular techniques between 2010 and 2018 at our hospital were reviewed. Patients older than 16 years with angiographic follow-up of at least 6 months after endovascular treatment were entered in the study. The patients had a mean follow-up of 12 months. The data were assessed for clinical outcome (modified Rankin Scale), permanent neurological deficit, post-operative complications, and optimal imaging outcome, defined by complete exclusion of AVM. The independent predictive variables of poor outcome or hemorrhagic complication were assessed using binary logistic regression. RESULTS Sixty-five patients with 65 AVMs were included in the study. Mean age of the patients was 40.0±14.4. Most common presentation was hemorrhage (61.5%). The patients underwent one to eight endovascular procedures (median=2). Mean nidus diameter was 30.2±13.0. A complete obliteration of AVM was achieved in 57 patients (87.7%). Post-procedure significant hemorrhagic and ischemic complications were seen in 13 (20%) and five (7.7%) patients respectively, leading to five (7.7%) transient and four (6.2%) permanent neurological deficits. Eight patients (12.3%) experienced worsening of mRS after embolization. Ten patients (15.4%) had poor outcome (mRS 3-5) at follow-up and two (3%) died. CONCLUSIONS Endovascular treatment can achieve a high rate of complete exclusion of grade III AVM but may be associated (as in other treatment modalities) with significant important complications. CLINICAL TRIAL REGISTRATION NUMBER NCT02879071.
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Affiliation(s)
- Humain Baharvahdat
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France.,Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran (the Islamic Republic of)
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Robert Fahed
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France.,Medicine - Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ashkan Pooyan
- Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran (the Islamic Republic of)
| | - Ashkan Mowla
- Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - François Delvoye
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | | | - Hocine Redjem
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Gabriele Ciccio
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Stanislas Smajda
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Mylène Hamdani
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
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9
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Santin MDN, Todeschi J, Pop R, Baloglu S, Ollivier I, Beaujeux R, Proust F, Cebula H. A combined single-stage procedure to treat brain AVM. Neurochirurgie 2020; 66:349-358. [PMID: 32574612 DOI: 10.1016/j.neuchi.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/04/2020] [Accepted: 03/07/2020] [Indexed: 11/29/2022]
Abstract
Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.
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Affiliation(s)
- M D N Santin
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - J Todeschi
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - R Pop
- Service de neuroradiologie interventionnelle, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - S Baloglu
- Service de neuroradiologie diagnostique (radiologie 2), hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - I Ollivier
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - R Beaujeux
- Service de neuroradiologie interventionnelle, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - F Proust
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - H Cebula
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
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Gallardo F, Martin C, Chang L, Diaz JF, Bustamante J, Rubino P. Utilidad de las Escalas de Gradación en el Tratamiento Quirúrgico de Malformaciones Arteriovenosas Cerebrales. Surg Neurol Int 2019; 10:S46-S57. [PMID: 32300491 PMCID: PMC7159054 DOI: 10.25259/sni_454_2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 11/26/2022] Open
Abstract
Introducción: Las malformaciones arteriovenosas (MAVs) cerebrales comprenden una compleja pato-logía responsable de hasta el 38% de las hemorragias en pacientes de entre 15-45 años, acarreando cada episodio de sangrado un 25-50% de morbilidad y un 10-20% de mortalidad. La decisión terapéu-tica en un paciente con una MAV debe tener en cuenta la comparación entre los riesgos propios de la intervención y los de la historia natural de esta enfermedad. Objetivo: Evaluar la utilidad de predecir riesgo quirúrgico de diferentes escalas de gradación de MAV cerebrales según nuestra experiencia en una serie de casos. Material y Métodos: Se realizó un análisis bibliográfico de escalas de gradación de riesgo quirúrgico de MAV cerebrales utilizando como motor de búsqueda Pubmed incluyendo como palabras clave “malformación arteriovenosa cerebral”y “scala de gradación” (brain arteriovenous and malfor- mation grading scale). Se analizaron de forma retrospectiva aquellos pacientes intervenidos quirúrgi-camente por MAV en este hospital público, se las clasificó acorde a las escalas analizadas y se compa-raron los resultados obtenidos con los previstos en ellas. Resultados: Se analizaron 90 pacientes intervenidos quirúrgicamente por MAV, sin tratamiento coad-yuvante. De forma retrospectiva se los agrupó acorde a las escalas de Spetzler Martin (SM), Spetzler-Ponce (SP) y suplementaria de Lawton. Las MAV grado 3 se subclasificaron según las escalas de Lawton y de de Oliveira. Considerando buenos resultados aquellos con Rankin modificado (mRs) igual o menor a 2. Con un rango de seguimiento de 12 a 48 meses, encontramos buenos resultados en el 100% de MAV SM grado 1, 91.7% de las grado 2, 80% en grado 3 y 42.9% en grado 4. Utilizando la escala SP, 93.7% de buenos resultados en tipo A, 80% en tipo B y 42.9% en tipo C. Subclasifican-do las MAV SM 3 acorde a las escalas de de Oliveira y Lawton, 84% de buenos resultados en el tipo 3A, 71.3% en las 3B, 92% en MAV tipo 3-, 72.1% en el tipo 3+, 60% en tipo 3. Utilizando la escala suplementaria de Lawton combinada con SM, buen resultado en 100% grados II y III, 85,7% grado IV, 87,6 grado V, 80% grado VI, 75% grado VII y 66,6% grado VIII. Conclusión: Reafirmamos en esta serie, la utilidad de estimar riesgo quirúrgico con las escalas SM, SP, y la subclasificación de las MAV grado 3 propuesta por Lawton. Y principalmente el utilizar la escala suplementaria de Lawton-Young al considerar el tratamiento quirúrgico de los pacientes con MAV que sangraron.
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Kocer N, Kandemirli SG, Dashti R, Kizilkilic O, Hanimoglu H, Sanus GZ, Tunali Y, Tureci E, Islak C, Kaynar MY. Single-stage planning for total cure of grade III-V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection. Neuroradiology 2018; 61:195-205. [PMID: 30488257 DOI: 10.1007/s00234-018-2140-z] [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: 03/27/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE There are no established guidelines for treatment of Spetzler-Martin grade III-V brain arteriovenous malformations (bAVMs). The purpose of this study is to report our institutional experience in total obliteration/eradication of grade III-V bAVMs by single-stage planning of embolization combined with microsurgical resection when necessary. METHODS All patients harboring Spetzler-Martin (S-M) grade III-V bAVMs treated with single-stage planning between January 2006 and January 2018 were retrospectively reviewed. This treatment paradigm is applicable only to surgically accessible bAVMs and does not include deep-seated bAVMs. Indications for treatment, clinical presentation, imaging characteristics, and treatment outcomes were analyzed. Outcomes were assessed based on modified Rankin Scale. RESULTS A total of 31 patients were identified. Seventeen patients (54.8%) presented with hemorrhage, 10 (32.3%) with seizures, 3 (9.7%) with headaches, and 1 (3.2%) with progressive neurological deficit. Based on S-M grading system, 25 patients (80.6%) harbored grade III bAVM, 5 patients had grade IV bAVMs (16.1%), and 1 patient (3.2%) had a grade V bAVM. There were no treatment-related complications in 24/31 (77.4%) patients. Of the total of seven patients with complications, four patients had clinical deterioration. The long-term (> 6-month), non-disabling morbidity (mRS ≤ 2) rate was 6.5%. The long-term, disabling morbidity rate was 3.2% with a mortality of 3.2%. Complete angiographic obliteration was achieved in 30/31 (96.8%) patients. CONCLUSION Single-stage treatment strategy can be considered as an alternative to multistage embolization prior to surgery in grade III-V bAVMs. In this study, a high rate of total obliteration with relatively low rates of permanent morbidity and mortality was achieved.
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Affiliation(s)
- Naci Kocer
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey.
| | - Sedat Giray Kandemirli
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Reza Dashti
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Osman Kizilkilic
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Hakan Hanimoglu
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yusuf Tunali
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ercan Tureci
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Mehmet Yasar Kaynar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Dinc N, Platz J, Tritt S, Quick-Weller J, Eibach M, Wolff R, Berkefeld J, Seifert V, Marquardt G. Posterior fossa AVMs: Increased risk of bleeding and worse outcome compared to supratentorial AVMs. J Clin Neurosci 2018; 53:171-176. [DOI: 10.1016/j.jocn.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 02/07/2018] [Accepted: 04/08/2018] [Indexed: 10/14/2022]
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13
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Multimodality Management of Spetzler-Martin Grade 3 Brain Arteriovenous Malformations with Subgroup Analysis. World Neurosurg 2017; 102:263-274. [DOI: 10.1016/j.wneu.2017.03.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 11/18/2022]
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14
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Ryu B, Ishikawa T, Kawamata T. Multimodal Treatment Strategy for Spetzler-Martin Grade III Arteriovenous Malformations of the Brain. Neurol Med Chir (Tokyo) 2017; 57:73-81. [PMID: 27169498 PMCID: PMC5341343 DOI: 10.2176/nmc.ra.2016-0056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The Spetzler–Martin (S–M) grading scale was developed to assess the risk of postoperative neurological complications after the surgical treatment of arteriovenous malformations (AVMs) of the brain. Treatment-associated morbidity and poor outcomes are particularly relevant to Grade III AVMs and improving the safety while attaining acceptable cure rates still poses a challenge. A multimodal treatment strategy combining surgery, embolization, and radiosurgery is recommended for S–M Grade III AVMs because of the surgical risk. Grade III AVMs are the heterogeneous group that has been further divided into subgroups according to the size, the location in eloquent cortex, and the presence of deep venous drainage. The risks associated with different treatment modalities vary depending on the subgroup, and the rating scales have been further refined to predict the risk more accurately and help determine the most appropriate treatment choice. Previous results for the treatment of S–M Grade III AVMs vary widely among studies, and the treatment modalities are also different in each study. Being familiar with previous treatment results is essential for improving treatment outcomes.
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Affiliation(s)
- Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University
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15
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Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations: an international multicenter study. J Neurosurg 2016; 126:859-871. [PMID: 27081906 DOI: 10.3171/2016.1.jns152564] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Because of the angioarchitectural diversity of Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs), the management of these lesions is incompletely defined. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after stereotactic radiosurgery (SRS) for SM Grade III AVMs and to determine the factors predicting these outcomes. METHODS The authors analyzed and pooled data from patients with SM Grade III AVMs treated with SRS at 8 institutions participating in the International Gamma Knife Research Foundation. Patients with these AVMs and a minimum follow-up length of 12 months were included in the study cohort. An optimal outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Data were analyzed by univariate and multivariate regression analyses. RESULTS The SM Grade III AVM cohort comprised 891 patients with a mean age of 34 years at the time of SRS. The mean nidus volume, radiosurgical margin dose, and follow-up length were 4.5 cm3, 20 Gy, and 89 months, respectively. The actuarial obliteration rates at 5 and 10 years were 63% and 78%, respectively. The annual postradiosurgery hemorrhage rate was 1.2%. Symptomatic and permanent RICs were observed in 11% and 4% of the patients, respectively. Optimal outcome was achieved in 56% of the patients and was significantly more frequent in cases of unruptured AVMs (OR 2.3, p < 0.001). The lack of a previous hemorrhage (p = 0.037), absence of previous AVM embolization (p = 0.002), smaller nidus volume (p = 0.014), absence of AVM-associated arterial aneurysms (p = 0.023), and higher margin dose (p < 0.001) were statistically significant independent predictors of optimal outcome in a multivariate analysis. CONCLUSIONS Stereotactic radiosurgery provided better outcomes for patients with small, unruptured SM Grade III AVMs than for large or ruptured SM Grade III nidi. A prospective trial or registry that facilitates a comparison of SRS with conservative AVM management might further clarify the authors' observations for these often high-risk AVMs.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, and
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sherbrooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - 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
| | | | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, and
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Using a Machine Learning Approach to Predict Outcomes after Radiosurgery for Cerebral Arteriovenous Malformations. Sci Rep 2016; 6:21161. [PMID: 26856372 PMCID: PMC4746661 DOI: 10.1038/srep21161] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/12/2016] [Indexed: 11/08/2022] Open
Abstract
Predictions of patient outcomes after a given therapy are fundamental to medical practice. We employ a machine learning approach towards predicting the outcomes after stereotactic radiosurgery for cerebral arteriovenous malformations (AVMs). Using three prospective databases, a machine learning approach of feature engineering and model optimization was implemented to create the most accurate predictor of AVM outcomes. Existing prognostic systems were scored for purposes of comparison. The final predictor was secondarily validated on an independent site's dataset not utilized for initial construction. Out of 1,810 patients, 1,674 to 1,291 patients depending upon time threshold, with 23 features were included for analysis and divided into training and validation sets. The best predictor had an average area under the curve (AUC) of 0.71 compared to existing clinical systems of 0.63 across all time points. On the heldout dataset, the predictor had an accuracy of around 0.74 at across all time thresholds with a specificity and sensitivity of 62% and 85% respectively. This machine learning approach was able to provide the best possible predictions of AVM radiosurgery outcomes of any method to date, identify a novel radiobiological feature (3D surface dose), and demonstrate a paradigm for further development of prognostic tools in medical care.
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Surgical Management of Cranial and Spinal Arteriovenous Malformations. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00072-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chowdhury AH, Khan SU, Rahman KM, Hasan ATMH, Ghose SK, Haque B, Habib M, Mohammad QD. Clinical and morphological pattern of brain arteriovenous malformations (BAVMs) in a tertiary care hospital in Bangladesh. BMC Res Notes 2015; 8:745. [PMID: 26638150 PMCID: PMC4670723 DOI: 10.1186/s13104-015-1717-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 11/18/2015] [Indexed: 11/10/2022] Open
Abstract
Background We have conducted this study to examine the clinical and morphological pattern of brain arteriovenous malformations (BAVMs) along with their treatment and short term outcome in a tertiary care hospital in Bangladesh. This retrospective chart review was carried out from the records of neuro-endovascular
division at Department of Neurology, Dhaka Medical College Hospital (DMCH) from January 2010 to June 2013. A total 60 patients were evaluated. All the necessary information regarding the demographic, clinical, morphologic and treatment profile was gathered through a predesigned questionnaire. To our knowledge, we have the largest cohort of BAVM patients in Bangladesh and this is the first of this kind of study done in Bangladesh. Results The mean age at diagnosis was 30.3 years with a standard deviation of ±14.3 and the majority was teenagers (30 %). Intracerebral hemorrhage was the commonest (70 %) type of presentation at diagnosis, followed by headache (50 %), altered consciousness (50 %), vomiting (40 %) and seizure (40 %). Majority of the AVMs had feeders from anterior circulation (50 %) and most of the AVMs (73.3 %) were supplied from the main feeders, whereas the rest from distal vessels. Regarding venous drainage, AVMs drained mostly either to superficial (43.3 %) or deep (40 %) venous system. AVMs frequently had larger (40 %) nidus size and a slow to medium flow (60 %), through the nidus. An eloquent AVM location was found in 50 % of the patients. Intranidal aneurysm was found in 10 % AVM and angiopathic AVM in 13.3 %. Patients were treated by endovascular embolization (31) or surgical excision (11) or conservative approach. There was one event of death, both in embolization group and surgically treated group before discharge. The patients were followed up for 1.3 ± 0.8 years. The rate of rebleed was 6.6, 30 and 60 % during follow up in endovascular, surgical and conservatively treated group. Though five patients in conservative group died during this time, no deaths reported in intervention group (endovascular or surgery). Conclusion Intracerebral hemorrhages, headache, altered consciousness and seizure are common clinical presentations of AVM at diagnosis. The remarkable morphologic features are larger AVM size at eloquent location, medium to slow flow with frequent feeders from main vessels of anterior circulation and drainage to superficial venous systems. Endovascular embolization or surgical excision of AVM are relatively safe and effective and provides better short term outcome than conservative approach.
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Affiliation(s)
- Ahmed Hossain Chowdhury
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
| | - Sharif Uddin Khan
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
| | | | - A T M Hasibul Hasan
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
| | - Swapon Kumar Ghose
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
| | - Badrul Haque
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
| | - Mansur Habib
- Department of Neurology, Dhaka Medical College Hospital-2, 3rd Floor, Ramna, Dhaka, Bangladesh.
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Gamble AJ, Schaffer SG, Nardi DJ, Chalif DJ, Katz J, Dehdashti AR. Awake Craniotomy in Arteriovenous Malformation Surgery: The Usefulness of Cortical and Subcortical Mapping of Language Function in Selected Patients. World Neurosurg 2015; 84:1394-401. [DOI: 10.1016/j.wneu.2015.06.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
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20
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Cohen-Inbar O, Lee CC, Xu Z, Schlesinger D, Sheehan JP. A quantitative analysis of adverse radiation effects following Gamma Knife radiosurgery for arteriovenous malformations. J Neurosurg 2015; 123:945-53. [PMID: 25909572 DOI: 10.3171/2014.10.jns142264] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors review outcomes following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs) and their correlation to postradiosurgery adverse radiation effects (AREs). METHODS From a prospective institutional review board-approved database, the authors identified patients with a minimum of 2 years of follow-up and thin-slice T2-weighted MRI sequences for volumetric analysis. A total of 105 AVM patients were included. The authors analyzed the incidence and quantitative changes in AREs as a function of time after GKRS. Statistical analysis was performed to identify factors related to ARE development and changes in the ARE index. RESULTS The median clinical follow-up was 53.8 months (range 24-212.4 months), and the median MRI follow-up was 36.8 months (range 24-212.4 months). 47.6% of patients had an AVM with a Spetzler-Martin grade ≥ III. The median administered margin and maximum doses were 22 and 40 Gy, respectively. The overall obliteration rate was 70.5%. Of patients who showed complete obliteration, 74.4% developed AREs within 4-6 months after GKRS. Late-onset AREs (i.e., > 12 months) correlated to a failure to obliterate the nidus. 58.1% of patients who developed appreciable AREs (defined as ARE index > 8) proceeded to have a complete nidus obliteration. Appreciable AREs were found to be influenced by AVM nidus volume > 3 ml, lobar location, number of draining veins and feeding arteries, prior embolization, and higher margin dose. On the other hand, a minimum ARE index > 8 predicted obliteration (p = 0.043). CONCLUSIONS ARE development after radiosurgery follows a temporal pattern peaking at 7-12 months after stereotactic radiosurgery. The ARE index serves as an important adjunct tool in patient follow-up and outcome prediction.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;,Neurological Institute, Taipei Veteran General Hospital; and.,National Yang-Ming University, Taipei, Taiwan
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Schlesinger
- 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
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Almeida JP, Medina R, Tamargo RJ. Management of posterior fossa arteriovenous malformations. Surg Neurol Int 2015; 6:31. [PMID: 25745586 PMCID: PMC4348799 DOI: 10.4103/2152-7806.152140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/20/2014] [Indexed: 11/28/2022] Open
Abstract
Background: Posterior fossa arteriovenous malformations (AVMs) are rare vascular lesions, representing 7–15% of all intracranial AVMs. Although less frequent than supratentorial AVMs, they present higher rupture, morbidity, and mortality rates. Microsurgery, radiosurgery, and endovascular neurosurgery are treatment options for obliteration of those lesions. In this paper, we present a critical review of the literature about the management of posterior fossa AVM. Methods: A MEDLINE-based search of articles published between January 1960 and January 2014 was performed. The search terms: “Posterior fossa arteriovenous malformation,” “microsurgery,” “radiosurgery,” and “endovascular” were used to identify the articles. Results: Current data supports the role of microsurgery as the gold standard treatment for cerebellar AVMs. Brainstem AVMs are usually managed with radiotherapy and endovascular therapy; microsurgery is considered in cases of pial brainstem AVMs. Conclusions: Succsseful treatment of posterior fossa AVMs depend on an integrated work of neurosurgeons, radiosurgeons, and endovascular neurosurgery. Although the development of radiosurgery and endovascular techniques is remarkable, microsurgery remains as the gold standard treatment for most of those lesions.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Roberto Medina
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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Buell TJ, Ding D, Starke RM, Webster Crowley R, Liu KC. Embolization-induced angiogenesis in cerebral arteriovenous malformations. J Clin Neurosci 2014; 21:1866-71. [DOI: 10.1016/j.jocn.2014.04.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/31/2014] [Accepted: 04/05/2014] [Indexed: 12/13/2022]
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Flores BC, Klinger DR, Rickert KL, Barnett SL, Welch BG, White JA, Batjer HH, Samson DS. Management of intracranial aneurysms associated with arteriovenous malformations. Neurosurg Focus 2014; 37:E11. [DOI: 10.3171/2014.6.focus14165] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.
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Affiliation(s)
- Bruno C. Flores
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel R. Klinger
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kim l. Rickert
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel l. Barnett
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Babu G. Welch
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan A. White
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - H. Hunt Batjer
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Duke S. Samson
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Jeon HJ, Park KY, Kim SY, Lee JW, Huh SK, Lee KC. Surgical outcomes after classifying Grade III arteriovenous malformations according to Lawton’s modified Spetzler–Martin grading system. Clin Neurol Neurosurg 2014; 124:72-80. [DOI: 10.1016/j.clineuro.2014.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
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Burrow AM, Link MJ, Pollock BE. Is stereotactic radiosurgery the best treatment option for patients with a radiosurgery-based arteriovenous malformation score ≤ 1? World Neurosurg 2014; 82:1144-7. [PMID: 25014752 DOI: 10.1016/j.wneu.2014.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 04/08/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The best management of patients with brain arteriovenous malformations (BAVM) is controversial. The radiosurgery-based arteriovenous malformation (AVM) score (RBAS) was developed to predict outcomes for patients with BAVM having stereotactic radiosurgery (SRS). METHODS The RBAS is calculated for patients with BAVM having SRS at our center as part of our prospectively maintained SRS database (RBAS = [0.1] [AVM volume; cm(3)] + [0.02] [patient age; years] + [0.5] [AVM location; 0 = cerebral/cerebellar hemispheres/corpus callosum, 1 = basal ganglia/thalamus/brainstem]). Review of the SRS database from 1990 to 2009 identified 80 patients with a RBAS ≤1 and at least 1 year of follow-up. The primary end point of the study was a decline in modified Rankin Score. The mean follow-up after SRS was 68 months (range, 12-133). RESULTS The mean patient age was 25.2 years (range, 7-44). Seventy-six patients (95%) had superficially located BAVMs; the mean BAVM volume was 2.3 cm(3) (range, 0.1-8.0). The mean RBAS was 0.76 (range, 0.21-1.00). The patients' MRS before SRS was 0 (n = 52, 65%), 1 (n = 24, 30%), 2 (n = 3, 4%), and 3 (n = 1, 1%). BAVM obliteration was confirmed in 92% of patients with follow-up beyond 3 years (70/76; 95% confidence interval 84%-97%). No patient had a hemorrhage or a radiation-related complication after SRS. The observed rate of modified Rankin Score decrease after SRS was 0% (0/80; 95% confidence interval 0%-6%). CONCLUSIONS SRS provided a high rate of obliteration at very low risk for patients with BVAM with a RBAS ≤1. Patient outcomes after SRS are likely equivalent to resection for younger patients with small-volume BAVM who do not require a craniotomy for clot removal.
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Affiliation(s)
- Anthony M Burrow
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Venous Flow Rearrangement After Treatment of Cerebral Arteriovenous Malformations: A Novel Approach to Evaluate the Risks of Treatment. World Neurosurg 2014; 82:160-9. [DOI: 10.1016/j.wneu.2013.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 10/28/2012] [Accepted: 02/01/2013] [Indexed: 11/16/2022]
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Ding D, Yen CP, Xu Z, Starke RM, Sheehan JP. Radiosurgery for primary motor and sensory cortex arteriovenous malformations: outcomes and the effect of eloquent location. Neurosurgery 2014; 73:816-24; discussio 824. [PMID: 23867301 DOI: 10.1227/neu.0000000000000106] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Eloquent intracranial arteriovenous malformations (AVMs) located in the primary motor or somatosensory cortex (PMSC) carry a high risk of microsurgical morbidity. OBJECTIVE To evaluate the outcomes of radiosurgery on PMSC AVMs and compare them with radiosurgery outcomes in a matched cohort of noneloquent lobar AVMs. METHODS Between 1989 and 2009, 134 patients with PMSC AVMs underwent Gamma Knife radiosurgery with a median radiographic and clinical follow-up of 64 and 80 months, respectively. Seizure (40.3%) and hemorrhage (28.4%) were the most common presenting symptoms. Pre-radiosurgery embolization was performed in 33.6% of AVMs. Median AVM volume was 4.1 mL (range, 0.1-22.6 mL), and prescription dose was 20 Gy (range, 7-30 Gy). Cox regression analysis was performed to identify factors associated with obliteration. RESULTS The overall obliteration rate, including magnetic resonance imaging and angiography, after radiosurgery was 63%. Obliteration was achieved in 80% of AVMs with a volume less than 3 mL compared with 55% for AVMs larger than 3 mL. No previous embolization (P = .002) and a single draining vein (P = .001) were independent predictors of obliteration on multivariate analysis. The annual post-radiosurgery hemorrhage risk was 2.5%. Radiosurgery-related morbidity was temporary and permanent in 14% and 6% of patients, respectively. Comparing PMSC AVMs with matched noneloquent lobar AVMs, the obliteration rates and clinical outcomes after radiosurgery were not statistically different. CONCLUSION For patients harboring PMSC AVMs, radiosurgery offers a reasonable chance of obliteration with a relatively low complication rate. Eloquent location does not appear to confer the same negative prognostic value for radiosurgery that it does for microsurgery.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Kano H, Flickinger JC, Yang HC, Flannery TJ, Tonetti D, Niranjan A, Lunsford LD. Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations. J Neurosurg 2014; 120:973-81. [PMID: 24484227 DOI: 10.3171/2013.12.jns131600] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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 define the outcomes and risks of stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs). METHODS Between 1987 and 2009, SRS was performed in 474 patients with SM Grade III AVMs. The AVMs were categorized by scoring the size (S), drainage (D), and location (L): IIIa was a small AVM (S1D1L1, N = 282); IIIb was a medium/deep AVM (S2D1L0, N = 44); and IIIc was a medium/eloquent AVM (S2D0L1, N = 148). The median target volume was 3.8 ml (range 0.1-26.3 ml) and the margin dose was 20 Gy (range 13-25 Gy). Eighty-one patients (17%) underwent prior embolization, and 58 (12%) underwent prior resection. RESULTS At a mean follow-up of 89 months, the total obliteration rates documented by angiography or MRI for all SM Grade III AVMs increased from 48% at 3 years to 69% at 4 years, 72% at 5 years, and 77% at 10 years. The SM Grade IIIa AVMs were more likely to obliterate than other subgroups. The cumulative rate of hemorrhage was 2.3% at 1 year, 4.4% at 2 years, 5.5% at 3 years, 6.4% at 5 years, and 9% at 10 years. The SM Grade IIIb AVMs had a significantly higher cumulative rate of hemorrhage. Symptomatic adverse radiation effects were detected in 6%. CONCLUSIONS Treatment with SRS was an effective and relatively safe management option for SM Grade III AVMs. Although patients with residual AVMs remained at risk for hemorrhage during the latency interval, the cumulative 10-year 9% hemorrhage risk in this series may represent a significant reduction compared with the expected natural history.
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Zipfel GJ, Heros RC. Gamma Knife radiosurgery and arteriovenous malformations. J Neurosurg 2014; 120:955-7. [PMID: 24460493 DOI: 10.3171/2013.10.jns131763] [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]
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Ding D, Yen CP, Starke RM, Xu Z, Sun X, Sheehan JP. Radiosurgery for Spetzler-Martin Grade III arteriovenous malformations. J Neurosurg 2014; 120:959-69. [PMID: 24460487 DOI: 10.3171/2013.12.jns131041] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intracranial arteriovenous malformations (AVMs) are most commonly classified based on their Spetzler-Martin grades. Due to the composition of the Spetzler-Martin grading scale, Grade III AVMs are the most heterogeneous, comprising 4 distinct lesion subtypes. The management of this class of AVMs and the optimal treatment approach when intervention is indicated remain controversial. The authors report their experience with radiosurgery for the treatment of Grade III AVMs in a large cohort of patients. METHODS All patients with Spetzler-Martin Grade III AVMs treated with radiosurgery at the University of Virginia over the 20-year span from 1989 to 2009 were identified. Patients who had less than 2 years of radiological follow-up and did not have evidence of complete obliteration during that period were excluded from the study, leaving 398 cases for analysis. The median patient age at treatment was 31 years. The most common presenting symptoms were hemorrhage (59%), seizure (20%), and headache (10%). The median AVM volume was 2.8 cm(3), and the median prescription dose was 20 Gy. The median radiological and clinical follow-up intervals were 54 and 68 months, respectively. Univariate and multivariate Cox proportional hazards and logistic regression analysis were used to identify factors associated with obliteration, postradiosurgery radiation-induced changes (RIC), and favorable outcome. RESULTS Complete AVM obliteration was observed in 69% of Grade III AVM cases at a median time of 46 months after radiosurgery. The actuarial obliteration rates at 3 and 5 years were 38% and 60%, respectively. The obliteration rate was higher in ruptured AVMs than in unruptured ones (p < 0.001). Additionally, the obliteration rate for Grade III AVMs with small size (< 3 cm diameter), deep venous drainage, and location in eloquent cortex was higher than for the other subtypes (p < 0.001). Preradiosurgery AVM rupture (p = 0.016), no preradiosurgery embolization (p = 0.003), increased prescription dose (p < 0.001), fewer isocenters (p = 0.006), and a single draining vein (p = 0.018) were independent predictors of obliteration. The annual risk of postradiosurgery hemorrhage during the latency period was 1.7%. Two patients (0.5%) died of hemorrhage during the radiosurgical latency period. The rates of symptomatic and permanent RIC were 12% and 4%, respectively. Absence of preradiosurgery AVM rupture (p < 0.001) and presence of a single draining vein (p < 0.001) were independent predictors of RIC. Favorable outcome was observed in 63% of patients. Independent predictors of favorable outcome were no preradiosurgery hemorrhage (p = 0.014), increased prescription dose (p < 0.001), fewer isocenters (p = 0.014), deep location (p = 0.014), single draining vein (p = 0.001), and lower Virginia radiosurgery AVM scale score (p = 0.016). CONCLUSIONS Radiosurgery for Spetzler-Martin Grade III AVMs yields relatively high rates of obliteration with a low rate of adverse procedural events. Small and ruptured lesions are more likely to become obliterated after radiosurgery than large and unruptured ones.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Hypofractionated stereotactic radiosurgery in a large bilateral thalamic and Basal Ganglia arteriovenous malformation. Case Rep Neurol Med 2013; 2013:631028. [PMID: 24307961 PMCID: PMC3836296 DOI: 10.1155/2013/631028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 10/03/2013] [Indexed: 11/17/2022] Open
Abstract
Purpose. Arteriovenous malformations (AVMs) in the basal ganglia and thalamus have a more aggressive natural history with a higher morbidity and mortality than AVMs in other locations. Optimal treatment—complete obliteration without new neurological deficits—is often challenging. We present a patient with a large bilateral basal ganglia and thalamic AVM successfully treated with hypofractionated stereotactic radiosurgery (HFSRS) with intensity modulated radiotherapy (IMRT). Methods. The patient was treated with hypofractionated stereotactic radiosurgery to 30 Gy at margin in 5 fractions of 9 static fields with a minimultileaf collimator and intensity modulated radiotherapy. Results. At 10 months following treatment, digital subtraction angiography showed complete obliteration of the AVM. Conclusions. Large bilateral thalamic and basal ganglia AVMs can be successfully treated with complete obliteration by HFSRS with IMRT with relatively limited toxicity. Appropriate caution is recommended.
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Starke RM, Komotar RJ, Connolly ES. A Randomized Trial of Unruptured Brain Arteriovenous Malformations. Neurosurgery 2013; 73:N13-5. [DOI: 10.1227/01.neu.0000435114.33768.e3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Starke RM, Yen CP, Ding D, Sheehan JP. A practical grading scale for predicting outcome after radiosurgery for arteriovenous malformations: analysis of 1012 treated patients. J Neurosurg 2013; 119:981-7. [DOI: 10.3171/2013.5.jns1311] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors performed a study to review outcomes following Gamma Knife radiosurgery for cerebral arteriovenous malformations (AVMs) and to create a practical scale to predict long-term outcome.
Methods
Outcomes were reviewed in 1012 patients who were followed up for more than 2 years. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent, symptomatic, radiation-induced complication. Preradiosurgery patient and AVM characteristics predictive of outcome in multivariate analysis were weighted according to their odds ratios to create the Virginia Radiosurgery AVM Scale.
Results
The mean follow-up time was 8 years (range 2–20 years). Arteriovenous malformation obliteration occurred in 69% of patients. Postradiosurgery hemorrhage occurred in 88 patients, for a yearly incidence of 1.14%. Radiation-induced changes occurred in 387 patients (38.2%), symptoms in 100 (9.9%), and permanent deficits in 21 (2.1%). Favorable outcome was achieved in 649 patients (64.1%). The Virginia Radiosurgery AVM Scale was created such that patients were assigned 1 point each for having an AVM volume of 2–4 cm3, eloquent AVM location, or a history of hemorrhage, and 2 points for having an AVM volume greater than 4 cm3. Eighty percent of patients who had a score of 0–1 points had a favorable outcome, as did 70% who had a score of 2 points and 45% who had a score of 3–4 points. The Virginia Radiosurgery AVM Scale was still predictive of outcome after controlling for predictive Gamma Knife radiosurgery treatment parameters, including peripheral dose and number of isocenters, in a multivariate analysis. The Spetzler-Martin grading scale and the Radiosurgery-Based Grading Scale predicted favorable outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.
Conclusions
Gamma Knife radiosurgery can be used to achieve long-term AVM obliteration and neurological preservation in a predictable fashion based on patient and AVM characteristics.
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Rodríguez-Hernández A, Kim H, Pourmohamad T, Young WL, Lawton MT. Cerebellar arteriovenous malformations: anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery 2013; 71:1111-24. [PMID: 22986595 DOI: 10.1227/neu.0b013e318271c081] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anatomic diversity among cerebellar arteriovenous malformations (AVMs) calls for a classification that is intuitive and surgically informative. Selection tools like the Spetzler-Martin grading system are designed to work best with cerebral AVMs but have shortcomings with cerebellar AVMs. OBJECTIVE To define subtypes of cerebellar AVMs that clarify anatomy and surgical management, to determine results according to subtypes, and to compare predictive accuracies of the Spetzler-Martin and supplementary systems. METHODS From a consecutive surgical series of 500 patients, 60 had cerebellar AVMs, 39 had brainstem AVMs and were excluded, and 401 had cerebral AVMs. RESULTS Cerebellar AVM subtypes were as follows: 18 vermian, 13 suboccipital, 12 tentorial, 12 petrosal, and 5 tonsillar. Patients with tonsillar and tentorial AVMs fared best. Cerebellar AVMs presented with hemorrhage more than cerebral AVMs (P < .001). Cerebellar AVMs were more likely to drain deep (P = .04) and less likely to be eloquent (P < .001). The predictive accuracy of the supplementary grade was better than that of the Spetzler-Martin grade with cerebellar AVMs (areas under the receiver-operating characteristic curve, 0.74 and 0.59, respectively). The predictive accuracy of the supplementary system was consistent for cerebral and cerebellar AVMs, whereas that of the Spetzler-Martin system was greater with cerebral AVMs. CONCLUSION Patients with cerebellar AVMs present with hemorrhage more often than patients with cerebral AVMs, justifying an aggressive treatment posture. The supplementary system is better than the Spetzler-Martin system at predicting outcomes after cerebellar AVM resection. Key components of the Spetzler-Martin system such as venous drainage and eloquence are distorted by cerebellar anatomy in ways that components of the supplementary system are not.
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Affiliation(s)
- Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA
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Rodríguez-Boto G, Gutiérrez-González R, Gil A, Serna C, López-Ibor L. Combined staged therapy of complex arteriovenous malformations: initial experience. Acta Neurol Scand 2013; 127:260-7. [PMID: 22881486 DOI: 10.1111/j.1600-0404.2012.01706.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Definitive treatment of complex supratentorial arteriovenous malformations (AVMs) has been classically assigned to ruptured or progressively symptomatic cases. The aim of this study is to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery. MATERIAL AND METHODS Thirteen consecutive patients with supratentorial Spetzler-Martin grades III, IV and V AVMs were treated between January 2009 and June 2010. Mean age at the beginning of the therapy was 34. All patients were symptomatic. Mean AVM size was 48 mm, and mean volume prior to embolization was 47 ml. RESULTS Mean number of endovascular procedures was 3, and mean volumetric obliteration prior to surgery was 79.2%. Mean time between two embolizations was 24 days. One patient showed a non-disabling complication after endovascular procedures. Mean time between the last embolization and surgery was 42 days. Two patients showed disabling complications after surgery, and one patient showed a non-disabling complication. Follow-up angiography showed the complete removal of permeable AVM in all patients. According to the modified Rankin Scale, all patients were non-dependent concerning daily life activity at 6-month follow-up. One-year follow-up angiography has been performed in 11 patients so far showing an absence of permeable AVM in spite of the remainder intravascular Onyx. CONCLUSIONS Staged preoperative embolization with Onyx followed by microsurgery has made possible 100% cure of complex AVMs with 0% mortality, 15.4% disabling complications and 15.4% non-disabling complications. Complete Onyx resection is not essential to achieve the cure of the patient.
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Affiliation(s)
| | | | - A. Gil
- Department of Interventional Neuroradiology; Clínico San Carlos University Hospital; Madrid; Spain
| | - C. Serna
- Department of Neurology; Clínico San Carlos University Hospital; Madrid; Spain
| | - L. López-Ibor
- Department of Interventional Neuroradiology; Clínico San Carlos University Hospital; Madrid; Spain
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Lepski G, Honegger J, Liebsch M, Sória MG, Narischat P, Ramina KF, Nägele T, Ernemann U, Tatagiba M. Safe resection of arteriovenous malformations in eloquent motor areas aided by functional imaging and intraoperative monitoring. Neurosurgery 2013; 70:276-88; discussion 288-9. [PMID: 21946511 DOI: 10.1227/neu.0b013e318237aac5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial. OBJECTIVE To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation. METHODS We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale. RESULTS Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P < .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits. CONCLUSION Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.
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Affiliation(s)
- Guilherme Lepski
- Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Baden-Württemberg, Germany.
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Cetin I, Ates R, Dhaens J, Storme G. Retrospective analysis of linac-based radiosurgery for arteriovenous malformations and testing of the Flickinger formula in predicting radiation injury. Strahlenther Onkol 2012; 188:1133-8. [DOI: 10.1007/s00066-012-0180-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 07/02/2012] [Indexed: 11/24/2022]
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Huang PP, Rush SC, Donahue B, Narayana A, Becske T, Nelson PK, Han K, Jafar JJ. Long-term Outcomes After Staged-Volume Stereotactic Radiosurgery for Large Arteriovenous Malformations. Neurosurgery 2012; 71:632-43; discussion 643-4. [DOI: 10.1227/neu.0b013e31825fd247] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Stereotactic radiosurgery is an effective treatment modality for small arteriovenous malformations (AVMs) of the brain. For larger AVMs, the treatment dose is often lowered to reduce potential complications, but this decreases the likelihood of cure. One strategy is to divide large AVMs into smaller anatomic volumes and treat each volume separately.
OBJECTIVE:
To prospectively assess the long-term efficacy and complications associated with staged-volume radiosurgical treatment of large, symptomatic AVMs.
METHODS:
Eighteen patients with AVMs larger than 15 mL underwent prospective staged-volume radiosurgery over a 13-year period. The median AVM volume was 22.9 mL (range, 15.7-50 mL). Separate anatomic volumes were irradiated at 3- to 9-month intervals (median volume, 10.9 mL; range, 5.3-13.4 mL; median marginal dose, 15 Gy; range, 15-17 Gy). The AVM was divided into 2 volumes in 10 patients, 3 volumes in 5 patients, and 4 volumes in 3 patients. Seven patients underwent retreatment for residual disease.
RESULTS:
Actuarial rates of complete angiographic occlusion were 29% and 89% at 5 and 10 years. Five patients (27.8%) had a hemorrhage after radiosurgery. Kaplan-Meier analysis of cumulative hemorrhage rates after treatment were 12%, 18%, 31%, and 31% at 2, 3, 5, and 10 years, respectively. One patient died after a hemorrhage (5.6%).
CONCLUSION:
Staged-volume radiosurgery for AVMs larger than 15 mL is a viable treatment strategy. The long-term occlusion rate is high, whereas the radiation-related complication rate is low. Hemorrhage during the lag period remains the greatest source of morbidity and mortality.
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Affiliation(s)
- Paul P. Huang
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Stephen C. Rush
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Bernadine Donahue
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Ashwatha Narayana
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Tibor Becske
- Department of Radiology (Interventional Neuroradiology), NYU Langone Medical Center, New York, New York
| | - P. Kim Nelson
- Department of Radiology (Interventional Neuroradiology), NYU Langone Medical Center, New York, New York
| | - Kerry Han
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Jafar J. Jafar
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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Pandey P, Marks MP, Harraher CD, Westbroek EM, Chang SD, Do HM, Levy RP, Dodd RL, Steinberg GK. Multimodality management of Spetzler-Martin Grade III arteriovenous malformations. J Neurosurg 2012; 116:1279-88. [PMID: 22482792 DOI: 10.3171/2012.3.jns111575] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Grade III arteriovenous malformations (AVMs) are diverse because of their variations in size (S), location in eloquent cortex (E), and presence of central venous drainage (V). Because they may have implications for management and outcome, the authors evaluated these variations in the present study. METHODS Between 1984 and 2010, 100 patients with Grade III AVMs were treated. The AVMs were categorized by Spetzler-Martin characteristics as follows: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The occurrence of a new neurological deficit, functional status (based on modified Rankin Scale [mRS] score) at discharge and follow-up, and radiological obliteration were correlated with demographic and morphological characteristics. RESULTS One hundred patients (49 female and 51 male; age range 5-68 years, mean 35.8 years) were evaluated. The size of AVMs was less than 3 cm in 28 patients, 3-6 cm in 71, and greater than 6 cm in 1; 86 AVMs were located in eloquent cortex and 38 had central drainage. The AVMs were Type 1 in 28 cases, Type 2 in 60, Type 3 in 11, and Type 4 in 1. The authors performed embolization in 77 patients (175 procedures), surgery in 64 patients (74 surgeries), and radiosurgery in 49 patients (44 primary and 5 postoperative). The mortality rate following the management of these AVMs was 1%. Fourteen patients (14%) had new neurological deficits, with 5 (5%) being disabling (mRS score > 2) and 9 (9%) being nondisabling (mRS score ≤ 2) events. Patients with Type 1 AVMs (small size) had the best outcome, with 1 (3.6%) in 28 having a new neurological deficit, compared with 72 patients with larger AVMs, of whom 13 (18.1%) had a new neurological deficit (p < 0.002). Older age (> 40 years), malformation size > 3 cm, and nonhemorrhagic presentation predicted the occurrence of new deficits (p < 0.002). Sex, eloquent cortex, and venous drainage did not confer any benefit. In 89 cases follow-up was adequate for data to be included in the obliteration analysis. The AVM was obliterated in 78 patients (87.6%), 69 of them (88.5%) demonstrated on angiography and 9 on MRI /MR angiography. There was no difference between obliteration rates between different types of AVMs, size, eloquence, and drainage. Age, sex, and clinical presentation also did not predict obliteration. CONCLUSIONS Multimodality management of Grade III AVMs results in a high rate of obliteration, which was not influenced by size, venous drainage, or eloquent location. However, the development of new neurological deficits did correlate with size, whereas eloquence and venous drainage did not affect the neurological complication rate. The authors propose subclassifying the Grade III AVMs according to their size (< 3 and ≥ 3 cm) to account for treatment risk.
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Affiliation(s)
- Paritosh Pandey
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5327, USA
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A historical analysis of single-stage γ knife radiosurgical treatment for large arteriovenous malformations: evolution and outcomes. Acta Neurochir (Wien) 2012; 154:383-94. [PMID: 22173687 DOI: 10.1007/s00701-011-1245-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 11/25/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Large arteriovenous malformations (AVMs) remain challenging and difficult to treat, reflected by evolving strategies developed from simple radiosurgical plans, to encompass embolization and, recently, staged volume treatments. To establish a baseline for future practice, we reviewed our clinical experience. METHOD The outcomes for 492 patients (564 treatments) with AVMs >10 cm(3) treated by single-stage radiosurgery were retrospectively analysed in terms of planning, previous embolization and size. RESULTS Twenty-eight percent of the patients presented with haemorrhage at a median age of 29 years (range: 2-75). From 1986 to 1993 (157 patients) plans were simplistic, based on angiography using a median of 2 isocentres and a marginal dose of 23 Gy covering 45-70% of the AVM (median volume 15.7 cm(3)). From 1994 to 2000 (225 patients) plans became more sophisticated, a median of 5 isocentres was used, covering 64-95% of the AVM (14.6 cm(3)), with a marginal dose of 21 Gy. Since 2000, MRI has been used with angiography to plan for 182 patients. Median isocentres increased to 7 with similar coverage (62-94%) of the AVM (14.3 cm(3)) and marginal dose of 21 Gy. Twenty-seven percent, 30% and 52% of patients achieved obliteration at 4 years, respectively. The proportion of prior embolization increased from 9% to 44% during the study. Excluding the embolized patients, improvement in planning increased obliteration rates from 28% to 36% and finally 63%. Improving treatment plans did not significantly decrease the rate of persisting radiation-induced side effects (12-16.5%). Complication rate rose with increasing size. One hundred and twenty-three patients underwent a second radiosurgical treatment, with a 64% obliteration rate, and mild and rare complications (6%). CONCLUSIONS Better visualization of the nidus with multimodality imaging improved obliteration rates without changing morbidity. Our results support the view that prior embolization can make interpretation of the nidus more difficult, reducing obliteration rate. It will be important to see how results of staged volume radiosurgery compare with this historical material.
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Almefty K, Spetzler RF. Arteriovenous malformations and associated aneurysms. World Neurosurg 2012; 76:396-7. [PMID: 22152562 DOI: 10.1016/j.wneu.2011.06.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 06/24/2011] [Indexed: 10/14/2022]
Affiliation(s)
- Kaith Almefty
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Abstract
Object
The authors propose a 3-tier classification for cerebral arteriovenous malformations (AVMs). The classification is based on the original 5-tier Spetzler-Martin grading system, and reflects the treatment paradigm for these lesions. The implications of this modification in the literature are explored.
Methods
Class A combines Grades I and II AVMs, Class B are Grade III AVMs, and Class C combines Grades IV and V AVMs. Recommended management is surgery for Class A AVMs, multimodality treatment for Class B, and observation for Class C, with exceptions to the latter including recurrent hemorrhages and progressive neurological deficits. To evaluate whether combining grades is warranted from the perspective of surgical outcomes, the 3-tier system was applied to 1476 patients from 7 surgical series in which results were stratified according to Spetzler-Martin grades.
Results
Pairwise comparisons of individual Spetzler-Martin grades in the series analyzed showed the fewest significant differences (p < 0.05) in outcomes between Grades I and II AVMs and between Grades IV and V AVMs. In the pooled data analysis, significant differences in outcomes were found between all grades except IV and V (p = 0.38), and the lowest relative risks were found between Grades I and II (1.066) and between Grades IV and V (1.095). Using the pooled data, the predictive accuracies for surgical outcomes of the 5-tier and 3-tier systems were equivalent (receiver operating characteristic curve area 0.711 and 0.713, respectively).
Conclusions
Combining Grades I and II AVMs and combining Grades IV and V AVMs is justified in part because the differences in surgical results between these respective pairs are small. The proposed 3-tier classification of AVMs offers simplification of the Spetzler-Martin system, provides a guide to treatment, and is predictive of outcome. The revised classification not only simplifies treatment recommendations; by placing patients into 3 as opposed to 5 groups, statistical power is markedly increased for series comparisons.
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Starke RM, Komotar RJ, Connolly ES. Surgical Decision Making, Techniques, and Periprocedural Care of Cerebral Arteriovenous Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Amponsah K, Ellis TL, Chan MD, Bourland JD, Glazier SS, McMullen KP, Shaw EG, Tatter SB. Staged Gamma Knife Radiosurgery for Large Cerebral Arteriovenous Malformations. Stereotact Funct Neurosurg 2011; 89:365-71. [DOI: 10.1159/000329363] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 05/04/2011] [Indexed: 11/19/2022]
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Oleaga L, Dalal S, Weigele J, Hurst R, Lee J, Voorhees A, Melhem E. The role of time-resolved 3D contrast-enhanced MR angiography in the assessment and grading of cerebral arteriovenous malformations. Eur J Radiol 2010; 74:e117-21. [DOI: 10.1016/j.ejrad.2009.04.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 04/23/2009] [Indexed: 10/20/2022]
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Starke RM, Komotar RJ, Hwang BY, Fischer LE, Garrett MC, Otten ML, Connolly ES. Treatment guidelines for cerebral arteriovenous malformation microsurgery. Br J Neurosurg 2009; 23:376-86. [DOI: 10.1080/02688690902977662] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gross BA, Duckworth EAM, Getch CC, Bendok BR, Batjer HH. Challenging traditional beliefs: microsurgery for arteriovenous malformations of the basal ganglia and thalamus. Neurosurgery 2009; 63:393-410; discussion 410-1. [PMID: 18812951 DOI: 10.1227/01.neu.0000316424.47673.03] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Arteriovenous malformations of the basal ganglia and thalamus are often managed with radiosurgery or observation, without consideration of microsurgery. Given the devastating effects of hemorrhage from these lesions, the accumulating evidence that they bleed more frequently than their lobar counterparts should prompt more creative thinking regarding their management. METHODS A review of the endovascular, microsurgical, and radiosurgical literature for arteriovenous malformations of the basal ganglia and thalamus was performed, with close attention to surgical approaches, obliteration rates, and procedure-related complications. RESULTS A complete resection rate of 91% and a mortality rate of 2.4% were found across surgical series of these lesions. These contrast with a 69% rate of complete obliteration and a 5.3% mortality rate (from latency-period hemorrhage) found when compiling results across the radiosurgical literature. CONCLUSION Given an appropriate surgical corridor of access, often afforded by incident hemorrhage, arteriovenous malformations of the basal ganglia and thalamus should be considered for microsurgical extirpation with preoperative embolization. In experienced hands, this approach presents an expeditious and definitive opportunity to eliminate the risk of subsequent hemorrhage and resultant morbidity and mortality.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Pollock BE, Flickinger JC. MODIFICATION OF THE RADIOSURGERY-BASED ARTERIOVENOUS MALFORMATION GRADING SYSTEM. Neurosurgery 2008; 63:239-43; discussion 243. [DOI: 10.1227/01.neu.0000315861.24920.92] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bruce E. Pollock
- Departments of Neurological Surgery and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John C. Flickinger
- Departments of Radiation Oncology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Richling B, Killer M, Al-Schameri AR, Ritter L, Agic R, Krenn M. Therapy of brain arteriovenous malformations: multimodality treatment from a balanced standpoint. Neurosurgery 2007; 59:S148-57; discussion S3-13. [PMID: 17053597 DOI: 10.1227/01.neu.0000237408.95785.64] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The three therapeutic modalities for arteriovenous malformation (AVM) treatment (surgery, embolization, and radiotherapy) developed in the past years with specific tools, each tool with its own qualities. Soon after the implementation of embolization for treatment of AVMs, this technique was used in combination with microsurgery; since the development of radiosurgery, treatment algorithms combining embolization with surgery and eventual subsequent radiosurgery, embolization with radiosurgery, or surgery with subsequent radiosurgery have been reported. These different combinations have been in use under the term multimodality treatment for many years, but the algorithms regarding the combination of tools, which tool has priority, and how the risk levels of each tool are assessed shows great variability among institutions. Centers with a surgical background see embolization as a technique to increase surgical feasibility and radiosurgery as a tool to complete subtotal AVM excision. Institutions with an endovascular background embolize AVMs with the aim of maximal occlusion rates and view surgery or radiosurgery as a technique to be used if the goal of total endovascular occlusion cannot be achieved. Radiosurgeons receive patients after incomplete embolization or surgical extirpation or a combination of both.
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Affiliation(s)
- Bernd Richling
- Department of Neurosurgery, Paracelsus Private Medical University, Salzburg, Austria
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