1
|
Bustuchina Vlaicu M. New approaches for brain arteriovenous malformations-related epilepsy. Rev Neurol (Paris) 2023; 179:188-200. [PMID: 36180290 DOI: 10.1016/j.neurol.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this review is to present the current literature and to highlight the most recent findings in brain arteriovenous malformations (bAVM)-related epilepsy research. METHODS We searched Medline, PubMed, Biblioinserm, Cochrane Central to study the latest research reports about the different factors that could be responsible for the genesis of bAVM-related epilepsy. We analyzed if epileptogenesis has any characteristics traits and its relation with the vascular malformation. The results of different treatments on epilepsy were considered. Typical errors that may lead towards incorrect or worse management of the seizures for these patients were also examined. RESULTS The development of bAVM results from multifactorial etiologies and bAVM-related epileptogenesis is likely specific for this pathology. Different types of evidence demonstrate a bidirectional relationship between bAVM and epilepsy. Currently, there is not enough published data to determine what may be the right management for these patients. CONCLUSIONS A better understanding of epileptogenesis in conjunction with knowledge of the complex alterations of structures and functions following bAVM-related seizures is necessary. Identification of biomarkers that can identify subgroups most likely to benefit from a specific intervention are needed to help guide clinical management. A new concept for the treatment of epilepsy related to an unruptured bAVM that cannot be treated invasively is proposed as well as new therapeutic perspectives. The next necessary step will be to propose additional algorithms to improve the development of future trials.
Collapse
Affiliation(s)
- M Bustuchina Vlaicu
- Pitié-Salpêtrière Hospital, Department of Neurosurgery, Paris, France; Inserm U0955, Translational Neuro-Psychiatry team, Créteil, France.
| |
Collapse
|
2
|
Treiber JM, Bayley JC, Curry D. Minimally Invasive Destructive, Ablative, and Disconnective Epilepsy Surgery. JOURNAL OF PEDIATRIC EPILEPSY 2023. [DOI: 10.1055/s-0042-1760106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AbstractConventional epilepsy surgery performed by microsurgical dissection typically requires large cranial working windows created with high-speed drills and lengthy incisions. In the past few decades, minimally invasive techniques have been developed with smaller incisions, comparable efficacy, shorter hospitalizations, and better safety profiles. These minimally invasive alternatives utilize stereotactic, ultrasonic, radiotherapeutic, and endoscopic techniques. Although not able to completely replace conventional surgery for all etiologies of epilepsy, these minimally invasive techniques have revolutionized modern epilepsy surgery and have been an invaluable asset to the neurosurgeon's repertoire. The endoscope has allowed for surgeons to have adequate visualization during resective and disconnective epilepsy surgeries using keyhole or miniature craniotomies. Modern stereotactic techniques such as laser interstitial thermal therapy and radiofrequency ablation can be used as viable alternatives for mesial temporal lobe epilepsy and can destroy lesional tissue deep areas without the approach-related morbidity of microsurgery such as with hypothalamic hamartomas. These stereotactic techniques do not preclude future surgery in the settings of treatment failure and have been used successfully after failed conventional surgery. Multiple ablation corridors can be performed in a single procedure that can be used for lesioning of large targets or to simplify treating multifocal epilepsies. These stereotactic techniques have even been used successfully to perform disconnective procedures such as hemispherotomies and corpus callosotomies. In patients unable to tolerate surgery, stereotactic radiosurgery is a minimally invasive option that can result in improved seizure control with minimal procedural risks. Advances in minimally invasive neurosurgery provide viable treatment options for drug-resistant epilepsy with quicker recovery, less injury to functional brain, and for patients that may otherwise not choose conventional surgery.
Collapse
Affiliation(s)
- Jeffrey M. Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - James C. Bayley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Daniel Curry
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, United States
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, United States
| |
Collapse
|
3
|
Lak AM, Cerecedo-Lopez CD, Cha J, Aziz-Sultan MA, Frerichs KU, Gormley WB, Mekary RA, Du R, Patel NJ. Seizure Outcomes After Interventional Treatment in Cerebral Arteriovenous Malformation-Associated Epilepsy: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 160:e9-e22. [PMID: 35364673 DOI: 10.1016/j.wneu.2021.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Seizures are the second most common presenting symptom of cerebral arteriovenous malformations (AVMs). Evidence supporting different treatment modalities is continuously evolving and it remains unclear which modality offers better seizure outcomes. OBJECTIVE To compare various interventional treatment modalities (i.e., microsurgery, radiosurgery, endovascular embolization, or multimodality treatment), regarding outcomes in AVM-associated epilepsy. METHODS PubMed, Embase, and Web of Science were searched on December 31, 2020 for studies that evaluated outcomes in patients with AVM-associated epilepsy after undergoing different treatment modalities. Pooled analysis was performed using a random-effects model and stratified by different modalities. RESULTS Forty-nine studies including 2668 patients were included. Interventional management was associated with a 56.0% probability of seizure freedom and a 73.0% probability of seizure improvement. The probability of discontinuing antiepileptic drugs was estimated at 38.0%. The stratified analysis showed that microsurgery was associated with a higher probability of seizure freedom and seizure improvement than was radiosurgery, endovascular, or multimodality treatment. The probability of antiepileptic drug cessation was also higher after microsurgery compared with radiation therapy; however, only clinical but not statistical significance could be inferred because of the lack of comparative analyses. CONCLUSIONS Interventional management of AVM-related epilepsy was associated with seizure freedom and seizure improvement in 56% and 73% of cases. Microsurgery seemed to be associated with a higher incidence of seizure freedom and seizure improvement than did other modalities. Future well-designed comparative studies are needed to draw definitive conclusions regarding each modality.
Collapse
Affiliation(s)
- Asad M Lak
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian D Cerecedo-Lopez
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Cha
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
4
|
Mamaril-Davis JC, Aguilar-Salinas P, Avila MJ, Nakaji P, Bina RW. Complete seizure-free rates following interventional treatment of intracranial arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1313-1326. [PMID: 34988732 DOI: 10.1007/s10143-021-01724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022]
Abstract
Seizures are common presenting symptoms of intracranial arteriovenous malformations (AVMs). This systematic review and meta-analysis aims to assess the current evidence regarding complete seizure freedom rates following surgical resection, stereotactic radiosurgery (SRS), and/or endovascular embolization of intracranial AVMs. A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality, spontaneous AVM-associated or hemorrhage-associated seizures, complete seizure-free rates following each interventional treatment, follow-up duration; determination methods of seizure outcomes, and average time-to-onset of recurrent seizures after each treatment. Manuscripts that described patients with nondisabling seizures or reduced seizure frequency in their seizure-free calculations were excluded. Seizure freedom rates following surgical resection, SRS, and endovascular embolization were compared via random-effect analysis. Thirty-four studies with a total of 1765 intracranial AVM patients presenting with spontaneous AVM-associated seizures and 408 patients presenting with hemorrhage-associated seizures were qualitatively analyzed. For patients presenting with AVM-associated seizures, the complete seizure-free rates were 73.0% (321/440 patients; 95% CI 68.8-77.1%) following surgical resection, 60.5% (376/622 patients; 95% CI 56.6-64.3%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following endovascular embolization alone. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the complete seizure-free rates were 73.0% (584/800 patients; 95% CI 69.9-76.1%) following surgical resection, 46.4% (572/1233 patients; 95% CI 43.6-49.2%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following embolization. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the overall improvements in seizure outcomes regardless of complete seizure freedom were 82.6% (661/800 patients; 95% CI 80.0-85.3%), 70.6% (870/1233 patients; 95% CI 68.0-73.1%), and 70.8% (46/65 patients; 95% CI 59.7-81.1%) following surgical resection, SRS, and embolization, respectively. No study reported information about the time-to-onset for recurrent seizures in any patient following treatment, as seizure outcomes were only described at the last follow-up visit. The available data suggests that surgical resection results in the highest rate of complete seizure freedom. The rate of seizure improvement following surgery increased further to 82.3% when including patients who had improved seizure frequency without achieving true seizure freedom. Complete seizure-free rates following SRS or embolization were more ambiguous and lower when compared to surgical resection. There is a need for high quality studies evaluating AVM treatment modalities and clearly defined seizure outcomes, as the current literature consists mostly of heterogenous patient populations.
Collapse
Affiliation(s)
- James C Mamaril-Davis
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA.
| |
Collapse
|
5
|
Capocci R, Bustuchina Vlaicu M, Shotar E, Mathon B, Delaitre M, Premat K, Talaat M, Talbi A, Boch AL, Lenck S, Carpentier A, Degos V, Sourour NA, Clarençon F. Benefits from Exclusion Treatment of Unruptured Brain Arteriovenous Malformations on Epilepsy in Adults. Clin Neuroradiol 2021; 32:749-760. [PMID: 34807285 DOI: 10.1007/s00062-021-01119-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE In approximately 30% of the patients, brain arteriovenous malformations (bAVMs) are revealed by seizures, which may alter the patients' quality of life. Our objective was to evaluate the benefits of exclusion treatment (radiosurgery, embolization and/or surgery) on posttherapeutic epilepsy in bAVM patients without intracranial hemorrhage prior to treatment. METHODS Our retrospective observational single-center study included all consecutive adult patients with an unruptured bAVM and epilepsy, treated at our institution from 1995 to 2019 and who were followed for at least 1 year. Data on angioarchitectural characteristics of bAVMs, on epilepsy and posttreatment modified Rankin Scale (mRS) were collected. The primary endpoint was a seizure-free status (defined as Engel class IA) after exclusion treatment versus conservative management. RESULTS In this study one hundred and one consecutive adult patients with bAVMs, epilepsy and without bAVM rupture before any treatment were included; 21 (21%) in the conservative management group vs. 80 (79%) in the exclusion treatment group. After exclusion treatment, 55% of the patients from the group were Engel IA after treatment vs. 10% of the conservative management group (odds ratio [OR] 11.37, 95% confidence interval [CI] 2.48-107.24, p < 0.001). CONCLUSION Our results suggest that exclusion treatment in unruptured bAVMs with epilepsy is associated with a higher seizure-free rate in comparison with conservative management. Data from randomized controlled studies are necessary to confirm these findings.
Collapse
Affiliation(s)
- Romain Capocci
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | | | - Eimad Shotar
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | | | - Kévin Premat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Maichael Talaat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Department of Radiology, Zagazig University Hospital, Zagazig, Egypt
| | - Atika Talbi
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Vincent Degos
- Sorbonne University Medical School, Paris, France.,Department of Neuro-Intensive Care, Pitie-Salpêtrière Hospital, Paris, France.,GRC BioFast. Paris VI University, Paris, France
| | - Nader Antoine Sourour
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne University Medical School, Paris, France. .,GRC BioFast. Paris VI University, Paris, France.
| |
Collapse
|
6
|
Sachdev S, Sita TL, Shlobin NA, Gopalakrishnan M, Sucholeiki R, Régis J, Bandt SK. Completion Corpus Callosotomy with Stereotactic Radiosurgery for Drug-Resistant, Intractable Epilepsy. World Neurosurg 2020; 143:440-444. [PMID: 32827745 DOI: 10.1016/j.wneu.2020.08.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) offers a noninvasive technique for division of the corpus callosum, which can confer improved seizure control to patients suffering from frequent atonic seizures due to rapid interhemispheric generalization. This noninvasive approach is well-suited for use in a palliative intervention for improved seizure control in this patient population. To our knowledge, this is the first report of radiosurgical completion corpus callosotomy in an adult in the United States. CASE DESCRIPTION A 20-year-old ambidextrous nonverbal man with a history of refractory generalized epilepsy status post open anterior corpus callosotomy at age 10 years, Lennox-Gastaut syndrome, and autism presented after 2 years of incremental, progressive deterioration in seizure control and behavior including 1 year. The family decided to pursue SRS corpus callosotomy. Under general anesthesia, a volume of interest encompassing a full midsagittal plane of the corpus callosum was defined to deliver 60 Gy to the 50% isodose line fully encompassing the target. Gamma Knife was used with 2 isocenters at 90° and 1 at 110° and isodose lines of 60, 20, and 12 Gy. Treatment was carried out without difficulty or complications while the patient remained under close monitoring. The patient was discharged the next day with a 2-week taper of dexamethasone. CONCLUSIONS Eight months postradiosurgical corpus callosotomy, the patient is free of atonic seizures and is ambulatory. In carefully selected cases and with protective radiosurgical planning, SRS for completion corpus callosotomy represents an effective option for refractory seizure control.
Collapse
Affiliation(s)
- Sean Sachdev
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Timothy L Sita
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mahesh Gopalakrishnan
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Roy Sucholeiki
- Department of Neurology, Northwestern Medicine Central Dupage Hospital, Winfield, Illinois, USA
| | - Jean Régis
- Functional and Stereotactic Neurosurgery Service and Gamma Knife Unit, Centre Hospitalier Universitaire La Timone Assistance Publique-Hopitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - S Kathleen Bandt
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| |
Collapse
|
7
|
Poletaeva II, Perepelkina OV, Nikolaev GM, Fedotova IB, Pleskacheva MG, Koshlan IV, Bogdanova YV, Koshlan NA, Pavlova GV, Revishchin AV. The Influence of Ionizing Radiation on Proneness to Audiogenic Seizure and Behavior in Krushinsky–Molodkina Rats. Biophysics (Nagoya-shi) 2020. [DOI: 10.1134/s0006350920040168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
8
|
Soldozy S, Norat P, Yağmurlu K, Sokolowski JD, Sharifi KA, Tvrdik P, Park MS, Kalani MYS. Arteriovenous malformation presenting with epilepsy: a multimodal approach to diagnosis and treatment. Neurosurg Focus 2020; 48:E17. [DOI: 10.3171/2020.1.focus19899] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
Arteriovenous malformation (AVM) presenting with epilepsy significantly impacts patient quality of life, and it should be considered very much a seizure disorder. Although hemorrhage prevention is the primary treatment aim of AVM surgery, seizure control should also be at the forefront of therapeutic management. Several hemodynamic and morphological characteristics of AVM have been identified to be associated with seizure presentation. This includes increased AVM flow, presence of long pial draining vein, venous outflow obstruction, and frontotemporal location, among other aspects. With the advent of high-throughput image processing and quantification methods, new radiographic attributes of AVM-related epilepsy have been identified. With respect to therapy, several treatment approaches are available, including conservative management or interventional modalities; this includes microsurgery, radiosurgery, and embolization or a combination thereof. Many studies, especially in the domain of microsurgery and radiosurgery, evaluate both techniques with respect to seizure outcomes. The advantage of microsurgery lies in superior AVM obliteration rates and swift seizure response. In addition, by incorporating electrophysiological monitoring during AVM resection, adjacent or even remote epileptogenic foci can be identified, leading to extended lesionectomy and improved seizure control. Radiosurgery, despite resulting in reduced AVM obliteration and prolonged time to seizure freedom, avoids the risks of surgery altogether and may provide seizure control through various antiepileptic mechanisms. Embolization continues to be used as an adjuvant for both microsurgery and radiosurgery. In this study, the authors review the latest imaging techniques in characterizing AVM-related epilepsy, in addition to reviewing each treatment modality.
Collapse
|
9
|
Dupic G, Biau J, Lemaire JJ, Ortholan C, Clavelou P, Lapeyre M, Colin P, Khalil T. [Functional stereotactic radiosurgery: Indications and perspectives]. Cancer Radiother 2020; 24:166-173. [PMID: 32220562 DOI: 10.1016/j.canrad.2020.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 01/03/2023]
Abstract
Stereotactic radiosurgery (SRS) is a non-invasive technique that enables to create brain focal lesions with a high precision and localization. Thus, functional brain disorders can be treated by SRS in case of pharmacoresistance or inoperability. To date, treatment of trigeminal neuralgia is the most described and known indication. Other indications will be developed in the future like movement disorders, refractory epilepsy, obsessive compulsive disorder and severe depression. We present here a review of actual and future indications of functional brain SRS with their level of evidence. All these SRS treatments have to be strictly conducted by trained teams with an excellent collaboration between radiation physicists, medical physicists, neurosurgeons, neurologists, psychiatrists and probably neuroradiologists.
Collapse
Affiliation(s)
- G Dupic
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - J Biau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - J J Lemaire
- Département de neurochirurgie, centre hospitalier universitaire Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - C Ortholan
- Département de radiothérapie, centre hospitalier Princesse-Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - P Clavelou
- Département de neurologie, centre hospitalier universitaire Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - M Lapeyre
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - P Colin
- Département de radiothérapie, Institut du cancer Courlancy, 38, rue de Courlancy, 51100 Reims, France
| | - T Khalil
- Département de neurochirurgie, centre hospitalier universitaire Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| |
Collapse
|
10
|
Niranjan A, Kashkoush A, Kano H, Monaco EA, Flickinger JC, Lunsford LD. Seizure control after radiosurgery for cerebral arteriovenous malformations: a 25-year experience. J Neurosurg 2018; 131:1763-1772. [PMID: 30554186 DOI: 10.3171/2018.7.jns18304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Seizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control. METHODS Patients with AVM who presented with a history of seizure and underwent SRS at the authors' institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6-295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up. RESULTS Seizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0-27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4-23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15-0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16-0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test). CONCLUSIONS This study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.
Collapse
|
11
|
Radiosurgery for epilepsy: Systematic review and International Stereotactic Radiosurgery Society (ISRS) practice guideline. Epilepsy Res 2017; 137:123-131. [DOI: 10.1016/j.eplepsyres.2017.08.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 08/27/2017] [Indexed: 10/18/2022]
|
12
|
Ditty BJ, Omar NB, Foreman PM, Miller JH, Kicielinski KP, Fisher WS, Harrigan MR. Seizure outcomes after stereotactic radiosurgery for the treatment of cerebral arteriovenous malformations. J Neurosurg 2017; 126:845-851. [DOI: 10.3171/2015.12.jns152461] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Patients with cerebral arteriovenous malformations (AVMs) commonly present with seizure. Seizure outcomes in patients treated with stereotactic radiosurgery (SRS) are poorly defined. A case series of patients with cerebral AVMs treated with SRS is presented to evaluate long-term seizure outcome.
METHODS
A retrospective review of the medical record was performed, identifying 204 consecutive patients with AVMs treated with SRS between January 1991 and June 2012. Clinical and radiographic data were evaluated. Seizure outcome was measured using the Engel Epilepsy Surgery Outcome Scale. Mean duration of follow-up was 37.1 months (SD 38.3 months) with a minimum follow-up period of 1 month.
RESULTS
Of the 204 patients with cerebral AVMs treated with SRS, 78 patients (38.2%) presented with seizures and 49 of those patients were treated with antiepileptic drugs (AEDs). Following SRS, 63 (80.8%) of the 78 patients who had had seizures prior to SRS were seizure-free at a mean follow-up time of 37.2 months (SD 41.3 months). Of the 49 patients who had been treated with AEDs, 17 were still taking AEDs at last follow-up. Of the 126 patients who did not present with seizures prior to treatment with SRS, only 5 patients (4.0%) had seizures in the post-SRS period. There was no significant correlation between post-SRS seizure status and patient demographic features, comorbidities, AVM characteristics, history of operative intervention, pre- or posttreatment hemorrhage, or radiographic degree of AVM resolution.
CONCLUSIONS
Stereotactic radiosurgery for treatment of cerebral AVMs is effective at providing long-term control of seizures. A substantial number of patients who were treated with SRS were not only seizure free at their last follow-up, but had been successfully weaned from antiepileptic medications.
Collapse
|
13
|
Teo MK, Young AMH, St George EJ. Comparative surgical outcome associated with the management of brain arteriovenous malformation in a regional neurosurgical centre. Br J Neurosurg 2016; 30:623-630. [PMID: 27341061 DOI: 10.1080/02688697.2016.1199776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Microsurgical resection of brain arteriovenous malformation (AVMs) is challenging, however, expert surgical series from large volume centres, have reported over 95% occlusion rates with 2 to 8% risk of morbidity & mortality. Data from a regional neurosurgical unit was analysed and compared with published series for the purposes of quality control. We also compared our surgical result with other treatment modalities from the whole AVM cohort managed over the same study period. DESIGN Retrospective analysis of a locally held AVM database. SUBJECTS Of the 141 AVM patients, 54 (35M, 19F, age range 9-68 years) underwent microsurgical removal of AVM by the senior author, from 2006 to 2012. 27 (19%), 18 (13%), 20 (14%), 22 (16%) had endovascular therapy only, radiosurgery only, combination therapy (endovascular and radiosurgery) and conservative management, respectively. METHODS Case notes were reviewed to determine clinical and radiological outcomes. Statistical analysis performed using SPSS with p < 0.05 defined as statistical significance. RESULTS In the surgical series, the Spetzler-Martin (SM) grade distribution was as follows: 17 grade I (32%), 31 grade II (57%), and 6 grade III (11%). 31 patients (57%) presented with intracranial haemorrhage, 12 patients (22%) with seizures. Of the 54 patients, 51 (94%) had angiographically confirmed obliteration of their AVM. Median follow-up for the entire cohort was 7 years. 83% of surgical patients have mRS 0-1, compared to 78%, 67%, 45%, 18% of patients managed by endovascular therapy, radiosurgery, combination therapy, conservative surveillance, respectively (p < 0.0001). However, the groups were not comparable in terms of SM grade or clinical presentation and the numbers in each group were relatively small. Seizure presentations were encountered in 23% (32/141) of the overall patients, and all the surviving patients were on anticonvulsants, except in the surgical arm, 7/12 (58%) patients were off their antiepileptic medications at last follow-up. CONCLUSIONS The results demonstrate a 94% surgical obliteration rate and 11% long-term neurological deficits for brain AVM patients managed surgically and were comparable to expert series. Achieving acceptable results is possible in lower volume settings, however, patient selection is important and the role of an experienced neurovascular team cannot be overstated.
Collapse
Affiliation(s)
- Mario K Teo
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
| | - Adam M H Young
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
| | - Edward J St George
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
| |
Collapse
|
14
|
Cerebral Arteriovenous Malformations and Epilepsy, Part 2: Predictors of Seizure Outcomes Following Radiosurgery. World Neurosurg 2015; 84:653-62. [DOI: 10.1016/j.wneu.2015.04.064] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022]
|
15
|
Przybylowski CJ, Ding D, Starke RM, Yen CP, Quigg M, Dodson B, Ball BZ, Sheehan JP. Seizure and anticonvulsant outcomes following stereotactic radiosurgery for intracranial arteriovenous malformations. J Neurosurg 2015; 122:1299-305. [PMID: 25614948 DOI: 10.3171/2014.11.jns141388] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Epilepsy associated with arteriovenous malformations (AVMs) has an unclear course after stereotactic radiosurgery (SRS). Neither the risks of persistent seizures nor the requirement for postoperative antiepileptic drugs (AEDs) are well defined. METHODS The authors performed a retrospective review of all patients with AVMs who underwent SRS at the University of Virginia Health System from 1989 to 2012. Seizure status was categorized according to a modified Engel classification. The effects of demographic, AVM-related, and SRS treatment factors on seizure outcomes were evaluated with logistic regression analysis. Changes in AED status were evaluated using McNemar's test. RESULTS Of the AVM patients with pre- or post-SRS seizures, 73 with pre-SRS epilepsy had evaluable data for subsequent analysis. The median patient age was 37 years (range 5-69 years), and the median follow-up period was 65.6 months (range 12-221 months). Sixty-five patients (89%) achieved seizure remission (Engel Class IA or IB outcome). Patients presenting with simple partial or secondarily generalized seizures were more likely to achieve Engel Class I outcome (p = 0.045). Twenty-one (33%) of 63 patients tapered off of pre-SRS AEDs. The incidence of freedom from AED therapy increased significantly after SRS (p < 0.001, McNemar's test). Of the Engel Class IA patients who continued AED therapy, 54% had patent AVM nidi, whereas only 19% continued AED therapy with complete AVM obliteration (p = 0.05). CONCLUSIONS Stereotactic radiosurgery is an effective treatment for long-term AVM-related epilepsy. Seizure-free patients on continued AED therapy were more likely to have residual AVM nidi. Simple partial or secondarily generalized seizure type were associated with better seizure outcomes following SRS.
Collapse
Affiliation(s)
| | - Dale Ding
- Departments of 1Neurological Surgery
| | | | | | | | | | | | - Jason P Sheehan
- Departments of 1Neurological Surgery.,3Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
16
|
Quigg M, Harden C. Minimally invasive techniques for epilepsy surgery: stereotactic radiosurgery and other technologies. J Neurosurg 2014; 121 Suppl:232-40. [DOI: 10.3171/2014.8.gks141608] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive surgical techniques for the treatment of medically intractable epilepsy, which have been developed by neurosurgeons and epileptologists almost simultaneously with standard open epilepsy surgery, provide benefits in the traditional realms of safety and efficacy and the more recently appreciated realms of patient acceptance and costs. In this review, the authors discuss the shortcomings of the gold standard of open epilepsy surgery and summarize the techniques developed to provide minimally invasive alternatives. These minimally invasive techniques include stereotactic radiosurgery using the Gamma Knife, stereotactic radiofrequency thermocoagulation, laser-induced thermal therapy, and MRI-guided focused ultrasound ablation.
Collapse
Affiliation(s)
- Mark Quigg
- 1Department of Neurology, University of Virginia Heath System, Charlottesville, Virginia; and
| | - Cynthia Harden
- 2Department of Neurology, Hofstra University, Hempsted, New York
| |
Collapse
|
17
|
Chen CJ, Chivukula S, Ding D, Starke RM, Lee CC, Yen CP, Xu Z, Sheehan JP. Seizure outcomes following radiosurgery for cerebral arteriovenous malformations. Neurosurg Focus 2014; 37:E17. [DOI: 10.3171/2014.6.focus1454] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Seizures are a common presentation of cerebral arteriovenous malformations (AVMs). The authors evaluated the efficacy of stereotactic radiosurgery (SRS) for the management of seizures associated with AVMs and identified factors influencing seizure outcomes following SRS for AVMs.
Methods
A systematic literature review was performed using PubMed. Studies selected for review were published in English, included at least 5 patients with both cerebral AVMs and presenting seizures treated with SRS, and provided post-SRS outcome data regarding obliteration of AVMs and/or seizures. Demographic, radiosurgical, radiological, and seizure outcome data were extracted and analyzed. All seizure outcomes were categorized as follows: 1) seizure free, 2) seizure improvement, 3) seizure unchanged, and 4) seizure worsened. Systematic statistical analysis was conducted to assess the effect of post-SRS AVM obliteration on seizure outcome.
Results
Nineteen case series with a total of 3971 AVM patients were included for analysis. Of these, 28% of patients presented with seizures, and data for 997 patients with available seizure outcome data who met the inclusion criteria were evaluated. Of these, 437 (43.8%) patients achieved seizure-free status after SRS, and 530 (68.7%) of 771 patients with available data achieved seizure control (seizure freedom or seizure improvement) following SRS. Factors associated with improved seizure outcomes following SRS for AVMs were analyzed in 9 studies. Seizure-free status was achieved in 82% and 41.0% of patients with complete and incomplete AVM obliteration, respectively. Complete AVM obliteration offered superior seizure-free rates compared with incomplete AVM obliteration (OR 6.13; 95% CI 2.16–17.44; p = 0.0007).
Conclusions
Stereotactic radiosurgery offers favorable seizure outcomes for AVM patients presenting with seizures. Improved seizure control is significantly more likely with complete AVM obliteration.
Collapse
Affiliation(s)
- Ching-Jen Chen
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Srinivas Chivukula
- 2 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dale Ding
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M. Starke
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 3 Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Po Yen
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 4 Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
18
|
Englot DJ, Chang EF. Rates and predictors of seizure freedom in resective epilepsy surgery: an update. Neurosurg Rev 2014; 37:389-404; discussion 404-5. [PMID: 24497269 DOI: 10.1007/s10143-014-0527-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 10/26/2013] [Accepted: 10/27/2013] [Indexed: 12/26/2022]
Abstract
Epilepsy is a debilitating neurological disorder affecting approximately 1 % of the world's population. Drug-resistant focal epilepsies are potentially surgically remediable. Although epilepsy surgery is dramatically underutilized among medically refractory patients, there is an expanding collection of evidence supporting its efficacy which may soon compel a paradigm shift. Of note is that a recent randomized controlled trial demonstrated that early resection leads to considerably better seizure outcomes than continued medical therapy in patients with pharmacoresistant temporal lobe epilepsy. In the present review, we provide a timely update of seizure freedom rates and predictors in resective epilepsy surgery, organized by the distinct pathological entities most commonly observed. Class I evidence, meta-analyses, and individual observational case series are considered, including the experiences of both our institution and others. Overall, resective epilepsy surgery leads to seizure freedom in approximately two thirds of patients with intractable temporal lobe epilepsy and about one half of individuals with focal neocortical epilepsy, although only the former observation is supported by class I evidence. Two common modifiable predictors of postoperative seizure freedom are early operative intervention and, in the case of a discrete lesion, gross total resection. Evidence-based practice guidelines recommend that epilepsy patients who continue to have seizures after trialing two or more medication regimens should be referred to a comprehensive epilepsy center for multidisciplinary evaluation, including surgical consideration.
Collapse
Affiliation(s)
- Dario J Englot
- UCSF Comprehensive Epilepsy Center, University of California, San Francisco, CA, USA,
| | | |
Collapse
|
19
|
McGonigal A, Bartolomei F, Gavaret M, Chauvel P, Régis J. Gamma Knife Radiosurgery of Paracentral Epilepsy. Stereotact Funct Neurosurg 2014; 92:346-53. [DOI: 10.1159/000364915] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/30/2014] [Indexed: 11/19/2022]
|
20
|
Wang JY, Yang W, Ye X, Rigamonti D, Coon AL, Tamargo RJ, Huang J. Impact on Seizure Control of Surgical Resection or Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2013; 73:648-55; discussion 655-6. [DOI: 10.1227/neu.0000000000000071] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Seizures are a common presenting symptom of arteriovenous malformations (AVMs). However, the impact of treatment modality on seizure control remains unclear.
OBJECTIVE:
To compare seizure control after surgical resection or radiosurgery for AVMs.
METHODS:
We analyzed retrospectively collected information for 378 patients with cerebral AVMs treated at our institution from 1990 to 2010. The application of strict inclusion criteria resulted in a study population of 164 patients.
RESULTS:
In our cohort, 31 patients (20.7%) had Spetzler-Martin grade I AVMs, 51 (34.0%) grade II, 47 (31.3%) grade III, 20 (13.3%) grade IV, and 1 (0.7%) grade V. Of the 49 patients (30%) presenting with seizures, 60.4% experienced seizure persistence after treatment. For these patients, radiosurgery was associated with seizure recurrence (odds ratio: 4.32, 95% confidence interval: 1.24-15.02, P = .021). AVM obliteration was predictive of seizure freedom at last follow-up (P = .002). In contrast, for patients presenting without seizures, 18.4% experienced de novo seizures after treatment, for which surgical resection was identified as an independent risk factor (hazard ratio: 8.65, 95% confidence interval: 3.05-24.5, P < .001).
CONCLUSION:
Although our data suggest that achieving seizure freedom should not be the primary goal of AVM treatment, surgical resection may result in improved seizure control compared with radiosurgery for patients who present with seizures. Conversely, in patients without presenting seizures, surgical resection increases the risk of new-onset seizures compared with radiosurgery, but primarily within the early posttreatment period. Surgical resection and radiosurgery result in divergent seizure control rates depending on seizure presentation.
Collapse
Affiliation(s)
- Joanna Y. Wang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L. Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J. Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
21
|
Abstract
Radiosurgery is commonly considered to be effective through a destructive physical mechanism acting on neural tissue. However, the results of modern neurophysiological, radiological, and histological studies are providing a basis on which to question this assumption. There are now multiple pieces of evidence pointing to a nonlesional mechanism of the radiosurgical action. It appears that tissue destruction is absent or minimal and in almost all cases insufficient to explain the clinical effects produced. There is a real possibility that radiosurgery induces changes in the functioning of neural tissue by differential effects on various neuronal populations and remodeling the glial environment, leading to modulation of function while preserving basic processing. Hence, the majority of radiosurgical procedures induce the desired biological effect without histological destruction of tissue. These findings may result in a major paradigm shift in the treatment of functional brain disorders.
Collapse
Affiliation(s)
- Jean Régis
- Department of Stereotactic and Functional Neurosurgery, Aix Marseille University, Timone University Hospital, and INSERM U751, 264 rue Saint Pierre, Marseille, 13385, Cedex 05, France.
| |
Collapse
|
22
|
Al-Shahi Salman R. The outlook for adults with epileptic seizure(s) associated with cerebral cavernous malformations or arteriovenous malformations. Epilepsia 2012; 53 Suppl 4:34-42. [PMID: 22946719 DOI: 10.1111/j.1528-1167.2012.03611.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cerebral cavernous malformations (CCMs) and arteriovenous malformations (AVMs) are common: their asymptomatic prevalence on brain magnetic resonance imaging (MRI) is 1 in 625 and 1 in 2,000, respectively. The risk of epileptic seizure(s) for people with AVMs and CCMs affects their domestic, social, and professional lives, and may influence their decisions about treatment. This article summarizes the seizure risks for people with AVMs and CCMs, gleaned from published original articles indexed in OVID Medline and Embase before 1 January 2012. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, a population-based study in Scotland, United Kingdom, found that the 5-year risks of first seizure were 8% for AVM and 4% for CCM; presentation with intracranial hemorrhage or focal neurologic deficit raised this risk for AVM (23%) but not for CCM (6%). Features associated with the occurrence of epileptic seizures for CCM are lesion multiplicity and cortical CCM location, whereas for AVM the most consistently reported associations are younger age, temporal location, cortical involvement, and nidus diameter >3 cm. In the absence of prior intracranial hemorrhage and nonhemorrhagic focal neurologic deficit, the 5-year risk of developing epilepsy following a first seizure is 58% for AVM and 94% for CCM, though there is no difference in the chance of achieving 2-year seizure freedom in this time frame (45% AVM vs. 47% CCM). Observational case series describe encouraging differences in seizure frequency before and after AVM and CCM treatment, but the shortage of studies demonstrating dramatic effects in comparison to concurrent control groups justifies the need for more controlled studies, ideally with randomized treatment allocation when the benefits of AVM or CCM treatment are uncertain.
Collapse
Affiliation(s)
- Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| |
Collapse
|
23
|
Vale FL, Bozorg AM, Schoenberg MR, Wong K, Witt TC. Long-term radiosurgery effects in the treatment of temporal lobe epilepsy. J Neurosurg 2012; 117:962-9. [DOI: 10.3171/2012.6.jns111905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epilepsy surgery is an effective treatment for medically resistant temporal lobe epilepsy (TLE). To minimize complication rates and potentially improve neuropsychology outcomes, stereotactic radiosurgery (SRS) has been explored as an alternative. Two pilot trials have demonstrated the effectiveness of SRS for the treatment of medically resistant TLE, with seizure-free outcomes for approximately 65% of patients at last follow-up. Despite encouraging results, no conclusive long-term outcomes are available for SRS. This article discusses a single patient who presented with recurrent seizures, worsening headaches, and persistent abnormal MRI findings 7 years and 8 months after SRS.
This 29-year-old woman with a history of medically refractory complex partial seizures since childhood was referred for evaluation. Medical management had failed in this patient. The workup was compatible with left mesial temporal lobe onset, with MRI findings suggestive of mesial temporal sclerosis. In 2003, at the age of 23 years, she underwent Gamma Knife surgery (GKS) targeting the left temporal mesial area with a dose of 24 Gy at the 50% marginal isodose line. After GKS, the patient's seizures decreased in frequency over several months, but auras were persistent. Nine months after treatment, she developed worsening headaches. A follow-up MRI study demonstrated a thick, irregular, enhancing lesion in the medial part of the temporal lobe. She was placed on corticosteroids, with resolution of her headaches.
Her seizures and headaches recurred in March 2010. An MRI study showed a 2.2-cm, ill-defined, enhancing cystic lesion in the left mesial temporal lobe with T2 and FLAIR hyperintensity, which was presumably radiation induced. At that time, the patient opted for left temporal lobe resection to control her seizures. Histological examination showed moderately severe, remote, longstanding sclerosis at the level of the hippocampus. A vascular lesion was identified, and it was most consistent with radiation-induced capillary hemangioma. The entorhinal region was severely damaged, with hemorrhage, necrosis, neuronal loss, astrogliosis, and hemosiderin deposition. There was evidence of radiation vasculopathy.
Radiation-induced lesions after SRS for the treatment of epilepsy are not well documented. Although GKS is a promising technique for the treatment of medically resistant TLE, the ideal candidate is not yet well defined. The selection of the appropriate technical parameters to obtain a desirable functional effect without histological damage to the surrounding neural tissue remains a challenge. This case illustrates the need for long-term follow-up when radiosurgery is used for epilepsy.
Collapse
Affiliation(s)
| | | | - Mike R. Schoenberg
- 1Departments of Neurosurgery,
- 2Neurology, and
- 3Psychiatry and Behavioral Neurosciences, University of South Florida
| | - Kondi Wong
- 4Department of Pathology, Tampa General Hospital, University of South Florida, Tampa, Florida; and
| | - Thomas C. Witt
- 5Goodman Campbell Brain and Spine, Department of Neurosurgery, Indiana University, Indianapolis, Indiana
| |
Collapse
|
24
|
Inoue HK, Negishi M, Hirato M, Ohye C. Treatment of unruptured arteriovenous malformations in the brain. J Clin Neurosci 2012; 5 Suppl:61-4. [PMID: 18639104 DOI: 10.1016/s0967-5868(98)90015-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/1996] [Accepted: 12/17/1996] [Indexed: 11/30/2022]
Abstract
Clinical features and treatment results of 33 patients with unruptured arteriovenous malformations (AVMs) were evaluated. Nine AVMs were located in the frontal lobe, 8 in the motor cortex, 5 in the parietal lobe, 6 in the temporal lobe, 2 in the occipital lobe and 3 in other parts of the brain. Nine patients were treated with microsurgery and 24 with radiosurgery. Total extirpation of the AVM was performed in all 9 microsurgery patients. One patient with an AVM in the motor cortex experienced upper extremity weakness postoperatively. Eleven of 24 patients treated with radiosurgery had follow-up imaging studies. Obliteration was obtained in 8 patients and decreased size in 3. Complications included 1 patient with a hemiparesis and 1 with an AVM rupture prior to obliteration. The remaining 13 patients did not experience any complications over a mean period of 21.2 months. Microsurgery appears to be the best treatment for unruptured AVMs in non-eloquent areas. Radiosurgery is a safe, effective treatment for unruptured AVMs in eloquent areas, although a bleeding risk remains during the latency period prior to obliteration.
Collapse
Affiliation(s)
- H K Inoue
- Department of Neurosurgery, Gunma University School of Medicine, Maebashi, Japan
| | | | | | | |
Collapse
|
25
|
|
26
|
Englot DJ, Young WL, Han SJ, McCulloch CE, Chang EF, Lawton MT. Seizure predictors and control after microsurgical resection of supratentorial arteriovenous malformations in 440 patients. Neurosurgery 2012; 71:572-80; discussion 580. [PMID: 22592327 PMCID: PMC5815296 DOI: 10.1227/neu.0b013e31825ea3ba] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Seizures are a common symptom of supratentorial arteriovenous malformations (AVMs), and uncontrolled epilepsy can considerably reduce patient quality of life. Potential risk factors for epilepsy in patients with AVMs are poorly understood, and the importance of achieving freedom from seizures in their surgical treatment remains underappreciated. OBJECTIVE To characterize risks factors for preoperative seizures and factors associated with postoperative freedom from seizures in patients with surgically resected supratentorial AVMs. METHODS We analyzed prospectively collected patient data for 440 patients who underwent microsurgical resection of supratentorial AVMs at our institution. RESULTS Among 440 patients with supratentorial AVMs, 130 (30%) experienced preoperative seizures, and 23 (18%) with seizures progressed to medically refractory epilepsy. Seizures were associated with a history of AVM hemorrhage (relative risk, 6.65; 95% confidence interval [CI], 3.81-11.6), male sex (relative risk, 2.07; 95% CI, 1.26-3.39), and frontotemporal lesion location (relative risk, 1.75; 95% CI, 1.05-2.93). After resection, 96% of patients had a modified Engel class I outcome, characterized by freedom from seizures (80%) or only 1 postoperative seizure (16%; mean follow-up, 20.7 ± 2.3 months). Comparable rates of postoperative seizures were seen in patients with (7%) or without (3%) preoperative seizures. AVMs with deep artery perforators were significantly associated with postoperative seizures (hazard ratio, 4.35; 95% CI, 1.61-11.7). CONCLUSION In the microsurgical treatment of supratentorial AVMs, hemorrhage, male sex, and frontotemporal location are associated with higher rates of preoperative seizures, whereas deep artery perforators are associated with postoperative seizures. Achieving freedom from seizure is an important goal that can be achieved in the surgical treatment of AVMs because epilepsy can significantly diminish patient quality of life.
Collapse
Affiliation(s)
- Dario J Englot
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA.
| | | | | | | | | | | |
Collapse
|
27
|
Josephson CB, Bhattacharya JJ, Counsell CE, Papanastassiou V, Ritchie V, Roberts R, Sellar R, Warlow CP, Al-Shahi Salman R. Seizure risk with AVM treatment or conservative management: prospective, population-based study. Neurology 2012; 79:500-7. [PMID: 22764257 DOI: 10.1212/wnl.0b013e3182635696] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To compare the risk of epileptic seizures in adults during conservative management or following invasive treatment for a brain arteriovenous malformation (AVM). METHODS We used annual general practitioner follow-up, patient questionnaires, and medical records surveillance to quantify the 5-year risk of seizures and the chances of achieving 2-year seizure freedom for adults undergoing AVM treatment compared to adults managed conservatively in a prospective, population-based observational study of adults in Scotland, newly diagnosed with an AVM in 1999-2003. RESULTS We identified 229 adults with a new diagnosis of an AVM, of whom two-thirds received AVM treatment (154/229; 67%) during 1,862 person-years of follow-up (median completeness of follow-up 97%). There was no significant difference in the proportions with a first or recurrent seizure over 5 years following AVM treatment, compared to the first 5 years following clinical presentation in conservatively managed adults, in analyses stratified by mode of presentation (intracerebral hemorrhage, 35% vs 26%, p = 0.5; seizure, 67% vs 72%, p = 0.6; incidental, 21% vs 10%, p = 0.4). For patients with epilepsy, the chances of achieving 2-year seizure freedom during 5-year follow-up were similar following AVM treatment (n = 39; 52%, 95% confidence interval [CI] 36% to 68%) or conservative management (n = 21; 57%, 95% CI 35% to 79%; p = 0.7). CONCLUSIONS In this observational study, there was no difference in the 5-year risk of seizures with AVM treatment or conservative management, irrespective of whether the AVM had presented with hemorrhage or epileptic seizures.
Collapse
Affiliation(s)
- Colin B Josephson
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Usami K, Kawai K, Koga T, Shin M, Kurita H, Suzuki I, Saito N. Delayed complication after Gamma Knife surgery for mesial temporal lobe epilepsy. J Neurosurg 2012; 116:1221-5. [DOI: 10.3171/2012.2.jns111296] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Despite the controversy over the clinical significance of Gamma Knife surgery (GKS) for refractory mesial temporal lobe epilepsy (MTLE), the modality has attracted attention because it is less invasive than resection. The authors report long-term outcomes for 7 patients, focusing in particular on the long-term complications.
Methods
Between 1996 and 1999, 7 patients with MTLE underwent GKS. The 50% marginal dose covering the medial temporal structures was 18 Gy in 2 patients and 25 Gy in the remaining 5 patients.
Results
High-dose treatment abolished the seizures in 2 patients and significantly reduced them in 2 others. One patient in this group was lost to follow-up. However, 2 patients presented with symptomatic radiation necrosis (SRN) necessitating resection after 5 and 10 years. One patient who did not need necrotomy continued to show radiation necrosis on MRI after 10 years. One patient died of drowning while swimming in the sea 1 year after GKS, before seizures had disappeared completely.
Conclusions
High-dose treatment resulted in sufficient seizure control but carried a significant risk of SRN after several years. Excessive target volume was considered as a reason for delayed necrosis. Drawbacks such as a delay in seizure control and the risk of SRN should be considered when the clinical significance of this treatment is evaluated.
Collapse
Affiliation(s)
- Kenichi Usami
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Kensuke Kawai
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Tomoyuki Koga
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Masahiro Shin
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Hiroki Kurita
- 2Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Saitama; and
| | - Ichiro Suzuki
- 3Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Nobuhito Saito
- 1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| |
Collapse
|
29
|
Cerebral arteriovenous malformations and seizures: differential impact on the time to seizure-free state according to the treatment modalities. Acta Neurochir (Wien) 2012; 154:1003-10. [PMID: 22492295 DOI: 10.1007/s00701-012-1339-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND To determine the prognostic factors for the incidence and the outcome of seizure in patients with cerebral arteriovenous malformation (AVM) and to identify the time to seizure-free state according to the treatment modalities. MATERIAL AND METHODS Between 1995 and 2008, the multidisciplinary team at our institution treated 399 patients with cerebral AVMs. Treatment consisted of surgical resection, radiosurgery, and embolization, either alone or in combination. The median follow-up period was 6.0 years (range, 3.0-16.2 years). Eighty-six patients (21.5 %) experienced seizures before treatment. We investigated the variables associated with seizure incidence and seizure outcome and analyzed the outcomes of seizure among each treatment modality. RESULTS After treatment, 60 (70 %) patients were seizure-free. Compared with 313 patients who did not experience seizures, we found that younger age (≤ 35 years), size ≥ 3 cm, and location of temporal lobe were associated with seizures (p < 0.05). Short seizure history, accompanying intracerebral hemorrhage, generalized tonic-clonic type seizure, deep-seated or infratentorial AVM, complete obliteration of AVM, and a favorable neurological outcome at 12 months were closely associated with Engel Class I outcomes (p < 0.05). Seizure-free outcomes after microsurgery, radiosurgery, or embolization were 78 %, 66 %, and 50 %, respectively. The overall annual bleeding rate was 1.0 % and 2.2 % in microsurgery-treated and radiosurgery-treated AVMs, respectively. In the surgery group, the median time to seizure-free status was 1.1 months (95 % CI, 0.7-1.2 months), whereas the radiosurgery group and embolization-alone group showed 20.5 months (95 % CI, 18.3-23.8 months), and 8.1 months (95 % CI, 6.0-13.5 months), respectively. CONCLUSIONS A multidisciplinary team approach for cerebral AVMs achieved satisfactory seizure control results. Microsurgery led to the highest percentage of seizure-free outcomes and had the lowest annual bleeding rate, whereas radiosurgery had a higher bleeding rate. Median time to seizure-free status in surgically treated patients was shorter than in patients who underwent radiosurgical or endovascular treatment.
Collapse
|
30
|
Abstract
Stereotactic radiosurgery, well established in the noninvasive treatment of focal lesions that are otherwise difficult to access through open surgery, is an emerging technology in the treatment of focal epileptic lesions. Recent studies suggest that seizures from hypothalamic hamartomas and mesial temporal lobe epilepsy remit at clinically significant rates with radiosurgery, but large variations among different studies have raised questions about appropriate treatment protocols and mechanisms. Proposed anticonvulsant mechanisms include neuromodulatory effects or ischemic necrosis of epileptic tissue. An ongoing trial that directly compares efficacy, morbidities, and cost of radiosurgery versus open surgery for mesial temporal lobe epilepsy is underway.
Collapse
Affiliation(s)
- Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, Virginia 22908, USA.
| | | | | |
Collapse
|
31
|
Jiang P, Lv X, Wu Z, Li Y, Jiang C, Yang X, Zhang Y. Characteristics of Brain Arteriovenous Malformations Presenting with Seizures without Acute or Remote Hemorrhage. Neuroradiol J 2011; 24:886-8. [PMID: 24059892 DOI: 10.1177/197140091102400610] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 05/08/2011] [Indexed: 02/05/2023] Open
Abstract
We report on the predictors of seizure presention in unruptured brain arteriovenous malformations (AVMs). Between 1999 and 2008, 302 consecutive patients with AVMs were referred to our institution for endovascular treatment. Seventy-four patients (24.5%) experienced seizures without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and seizure presentation. When we compared the 74 patients with seizures without hemorrhage with the 228 patients who did not experience seizures initially (total of 302 patients), male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage were statistically associated with seizures (P=0.016, P=0.002, P=0.022, P=0.005, and P=0.022, respectively). Posterior fossa and deep locations and coexisting aneurysms were statistically associated with no seizures. The angioarchitectural characteristics of AVM associated with seizure presentation include male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage.
Collapse
Affiliation(s)
- P Jiang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University; Beijing, China -
| | | | | | | | | | | | | |
Collapse
|
32
|
Is radiosurgery a neuromodulation therapy? J Neurooncol 2010; 98:155-62. [DOI: 10.1007/s11060-010-0226-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 05/06/2010] [Indexed: 11/25/2022]
|
33
|
Lv X, Li Y, Jiiang C, Yang X, Wu Z. Brain arteriovenous malformations and endovascular treatment: effect on seizures. Interv Neuroradiol 2010; 16:39-45. [PMID: 20377978 PMCID: PMC3277967 DOI: 10.1177/159101991001600105] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 03/04/2010] [Indexed: 02/05/2023] Open
Abstract
We report our experience in treating patients with seizures associated with brain arteriovenous malformations (AVM) without a clinical history of intracranial hemorrhage. Between 2001 and 2003, the neurovascular unit at Beijing Tiantan Hospital treated 109 patients with brain AVM endovascularly. Thirty patients (27.5%) experienced seizures before treatment. We studied the following factors: sex, age, AVM size, AVM location, seizure type, duration of seizure history, endovascular treatment and AVM obliteration. Clinical follow-up was via telephone interview. Thirty patients with seizure disorders due to brain AVMs were endovascularly treated. The age of the patients ranged from eight to 55 years. There were 22 males and eight females. The AVMs were smaller than 3 cm in five patients, between 3 cm and 6 cm in 22, and larger than 6 cm in three. The most frequent location of the AVMs was in the frontal, followed by the parietal, temporal and occipital lobes. Sixty-seven embolization procedures were performed and total obliteration was achieved in four patients. Two patients developed a hemiparesis and three suffered temporary dysphasia after embolization. Two patients had visual field deficits. There were no deaths. The results of post-embolization seizure control during the average follow-up period of 80 months were excellent in 21 patients, good in four, fair in two and poor in three. Successful seizure control can be obtained with endovascular embolization.
Collapse
Affiliation(s)
- X Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China.
| | | | | | | | | |
Collapse
|
34
|
Vojtěch Z, Vladyka V, Kalina M, Nešpor E, Seltenreichová K, Šemnická J, Liščák R. The use of radiosurgery for the treatment of mesial temporal lobe epilepsy and long-term results. Epilepsia 2009; 50:2061-71. [DOI: 10.1111/j.1528-1167.2009.02071.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Barbaro NM, Quigg M, Broshek DK, Ward MM, Lamborn KR, Laxer KD, Larson DA, Dillon W, Verhey L, Garcia P, Steiner L, Heck C, Kondziolka D, Beach R, Olivero W, Witt TC, Salanova V, Goodman R. A multicenter, prospective pilot study of gamma knife radiosurgery for mesial temporal lobe epilepsy: Seizure response, adverse events, and verbal memory. Ann Neurol 2009; 65:167-75. [DOI: 10.1002/ana.21558] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
36
|
[Radiosurgery for drug-resistant epilepsies: state of the art, results and perspectives]. Neurochirurgie 2008; 54:320-31. [PMID: 18417166 DOI: 10.1016/j.neuchi.2008.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 02/19/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is growing interest in the use of radiosurgery in epilepsy. We analyzed our experience in this field in an attempt to define the potential of radiosurgery in epileptology. MATERIAL AND METHODS [corrected] Our local clinical experience (134 patients), accumulated over the last 15 years, mainly includes treatment of temporal lobe epilepsy without space-occupying lesions (59 patients), including 53 with pure MTLE, 61 cases of hypothalamic hamartoma, two cases of callosotomy, and 12 other types of epilepsy. RESULTS The analysis of our material, as well as other clinical and experimental data, suggest that the use of radiosurgery is beneficial only to patients in whom a strict preoperative definition of the extent of the epileptogenic zone (or network) has been achieved and strict rules of dose planning have been applied. As soon as these principles are not observed, the risk of treatment failure and/or side effects increases dramatically. Long-term outcome data are now available and published for MTLE but not yet for other types of epilepsy. Long-term safety and efficacy in MTLE are comparable to surgical resection but radiosurgery has the advantage of sparing verbal memory in patients operated by Gamma Knife (GK) on the dominant side. In small hamartomas, the efficacy is comparable to microsurgery but with a dramatic reduction in risk. CONCLUSION The vast amount of clinical materiel and long-term evaluation now support the use of GK surgery in small hypothalamic hamartomas and MTLE when the patient is at risk of verbal memory loss.
Collapse
|
37
|
Prayson RA, Yoder BJ. Clinicopathologic findings in mesial temporal sclerosis treated with gamma knife radiotherapy. Ann Diagn Pathol 2007; 11:22-6. [PMID: 17240303 DOI: 10.1016/j.anndiagpath.2006.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Mesial temporal sclerosis (MTS) is the most common cause of medically intractable temporal lobe epilepsy. Histologic findings include hippocampal atrophy with neuronal loss in the dentate, CA1, and CA3/CA4 regions with gliosis. The conventional treatment of patients with intractable epilepsy secondary to MTS has been surgical excision. Gamma knife radiotherapy (GKR) has recently been suggested as a less invasive alternative to surgery. To date, the histologic changes that occur in this setting after GKR have not been well described. The clinicopathologic features of 4 patients with MTS who received GKR and underwent subsequent surgical resection or autopsy were retrospectively reviewed. The study group is composed of 4 patients (3 women, 1 men) with ages 55, 48, 22, and 20 years, respectively, at the time of GKR. There were 2 patients who had a history of infantile febrile seizures, and 2 who had a central nervous infection during infancy. All 4 patients had a long-standing (13-36 years) history of temporal lobe seizures resistant to medical management. Imaging studies, electroencephalogram, and surgical specimens all confirmed the diagnosis of MTS. The oldest of the 4 patients died 1 month after receiving GKR, presumably because of post-gamma knife persistent seizure complications. The postmortem neuropathology on this patient was unremarkable for any radiation effect changes but showed evidence of MTS. The remaining 3 patients underwent surgical resection for persistent seizures at 18, 22, and 20 months, respectively, post-gamma knife. These 3 surgical specimens showed variable degrees of radiation effect changes in the temporal lobe, hippocampus, and amygdala, including chronic (lymphocytes and macrophages) perivascular inflammation (3/3), vascular sclerosis (3/3), foci of edema with necrosis (3/3; extensive in 2 patients), reactive astrocytosis (3/3), microglial proliferation (1/3), and microcalcifications (1/3). Patients with MTS who underwent GKR can develop typical radiation changes over time. Treatment of individuals with MTS via GKR may not always be adequate in controlling seizures. Radiation therapy effect may contribute to persistent seizures after GKR in some patients with MTS.
Collapse
Affiliation(s)
- Richard A Prayson
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
| | | |
Collapse
|
38
|
Kwon KH, Lee JI, Hong SC, Seo DW, Hong SB. Gamma Knife Radiosurgery for Epilepsy Related to Dysembryoplastic Neuroepithelial Tumor. Stereotact Funct Neurosurg 2006; 84:243-7. [PMID: 17063046 DOI: 10.1159/000096498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Dysembryoplastic neuroepithelial tumor (DNT) is a well-known epileptogenic lesion with favorable seizure outcome after surgical resection. However, sometimes surgery may be difficult technically, and epilepsy may continue throughout the patient's lifetime despite surgical intervention. We report a case of intractable epilepsy related to DNT that was treated with gamma knife radiosurgery (GKRS). The frequency of seizure was reduced remarkably after GKRS, and finally a seizure-free state was accomplished in two years. Neuropsychological tests also showed improvement. It is suggested that GKRS may be an effective and less invasive alternative treatment for the patients in whom surgical treatment is difficult.
Collapse
Affiliation(s)
- Ki-Hun Kwon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | |
Collapse
|
39
|
Andrade-Souza YM, Ramani M, Scora D, Tsao MN, TerBrugge K, Schwartz ML. Radiosurgical treatment for rolandic arteriovenous malformations. J Neurosurg 2006; 105:689-97. [PMID: 17121129 DOI: 10.3171/jns.2006.105.5.689] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors reviewed the radiosurgical outcomes in patients with arteriovenous malformations (AVMs) located in the rolandic area, including the primary motor and sensory gyri.
Methods
The study population consisted of 38 patients with rolandic-area AVMs who underwent linear accelerator radiosurgery at the University of Toronto between 1989 and 2000. Obliteration rate, risk of hemorrhage during the latency period, radiation-induced complications, seizure control, and functional status were evaluated. Patients were also divided into two subgroups according to AVM volume (< 3 cm3 and ≥ 3 cm3).
Patients were followed up for a median of 42.4 months (range 30–103 months), and the median age of the patients was 40 years (range 12–67 years). The median AVM volume was 8.1 cm3 (range 0.32–21, mean 8.32 cm3), and the median dose at the tumor margin was 15 Gy (range 15–22, mean 16.8 Gy). The risk of hemorrhage after radiosurgery was 5.3% for the 1st year, 2.6% for the 2nd, and 0% for the 3rd. Two patients (5.3%) sustained adverse effects related to radiation for more than 6 months. Complete nidus obliteration after a single radiosurgical treatment was achieved in 23 patients (60.5%). The obliteration rate for AVMs smaller than 3 cm3 was 83.3% (10 of 12) and that for AVMs larger than or equal to 3 cm3 was 50% (13 of 26). Among the patients who had seizures as the initial presentation, 51.8% were free of seizures after radiosurgery and the seizure pattern improved in 40.7% during the 3rd and last year of follow up. Overall, excellent results (obliteration and no new or worsening neurological deficit) can be achieved in approximately 60% of patients. This percentage varies according to the AVM size and can reach 83% in patients with AVMs smaller than 3 cm3.
Conclusions
Radiosurgery is a safe and effective treatment for people with rolandic AVMs. The low rate of morbidity associated with radiosurgery, compared with other treatments, indicates that this method may be the first choice for patients with AVMs located in this area.
Collapse
Affiliation(s)
- Yuri M Andrade-Souza
- Division of Neurosurgery, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
40
|
Abstract
Radiosurgery is an emerging therapeutic approach for the treatment of medically intractable epileptogenic foci. A favourable seizure outcome was first reported in studies of the effects of radiosurgery in the treatment of arteriovenous malformations and tumours. Radiosurgery has since been applied to the treatment of complex partial seizures with mesial-temporal-lobe onset. Nearly simultaneously, experimental evidence supporting the usefulness of radiosurgery to improve or abolish seizures has confirmed that stereotactic irradiation can preferentially affect epileptogenic versus normal cortex. Further work is clearly needed, but this technique might become an important approach in the management of mesial-temporal and extratemporal epilepsy, especially if refractory seizures arise from eloquent cortex or surgically challenging regions of brain.
Collapse
|
41
|
Jenrow KA, Ratkewicz AE, Zalinski DN, Roszka KM, Lemke NW, Elisevich KV. Influence of ionizing radiation on the course of kindled epileptogenesis. Brain Res 2006; 1094:207-16. [PMID: 16762327 DOI: 10.1016/j.brainres.2006.03.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 03/29/2006] [Accepted: 03/30/2006] [Indexed: 10/24/2022]
Abstract
Several clinical and experimental reports suggest that low-dose irradiation of an established epileptic focus can reduce the occurrence of spontaneous seizures. Conversely, some recent reports suggest that under some conditions low-dose irradiation may have disinhibitory effects on seizure expression. Here, we have investigated mechanistic aspects of this phenomenon in the kindling model of epilepsy by applying focal irradiation at various points during kindling development. Rats were kindled to stage 5 by afterdischarge-threshold electrostimulation of the left amygdala. Treatment groups were irradiated using a collimated X-ray beam (18 MV) either prior to kindling, at kindling stage 3, or at kindling stage 5, by exposure of the left amygdala to a single-fraction central-axis dose of 25 Gy. Generalized seizure thresholds (GSTs) were subsequently assayed at weekly intervals for 10 weeks and at monthly intervals for an additional 3 months, along with the severity of the evoked seizures. Irradiation produced no significant effects on seizure threshold, but did produce persistent changes in seizure severity which varied as a function of the timing of irradiation. Relative to sham irradiated controls, the occurrence of stage 6 seizures was significantly increased by irradiation prior to kindling, but was unaffected by irradiation at kindling stage 3, and significantly reduced by irradiation at kindling stage 5. Quantitative immunohistochemical assays for neuron and astrocyte densities within the amygdala and hippocampus revealed only subtle changes in neuronal density within the dentate granule cell layer. These results are discussed in relation to mechanisms of seizure- and radiation-induced plasticity.
Collapse
Affiliation(s)
- Kenneth A Jenrow
- Department of Neurosurgery, Henry Ford Health Sciences Center, Henry Ford Hospital, Detroit, MI 48202, USA.
| | | | | | | | | | | |
Collapse
|
42
|
Lim YJ, Lee CY, Koh JS, Kim TS, Kim GK, Rhee BA. Seizure control of Gamma Knife radiosurgery for non-hemorrhagic arteriovenous malformations. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 99:97-101. [PMID: 17370773 DOI: 10.1007/978-3-211-35205-2_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVES Although radiosurgery has been found to be a safe and effective alternative treatment, seizure outcome of arteriovenous malformation (AVM) radiosurgery has not been documented in detail. We report the effect of Gamma Knife radiosurgery (GKRS) on seizures associated with AVMs and discuss the various factors that influence the prognosis. MATERIAL AND METHODS Between 1992 and 2004, 246 patients were treated with GKRS for AVMs at Kyung-Hee medical center. Forty five (17.0%) patients have non-hemorrhagic AVMs and presenting symptom was seizure. Two patients of all were excluded from this study due to loss of follow-up after radiosurgery. In this study, retrospective analysis of clinical characteristics, radiologic findings, radiosurgical seizure outcome were performed. RESULTS There were 32 male and 11 female with age ranging from 10 to 74 years (mean 35 years). Type of seizure included: general tonic clonic (n = 28); focal motor or sensory (n = 7); partial complex (n = 8). The location of AVM was temporal (n = 18); frontal (n = 9); deep seated (n = 7): parietal (n = 5); occipital (n = 4). Follow-up period was from 8 months to 12 years (mean 46 months). Mean volume was 6.2 cc (2.7-20), mean marginal and maximal dosage was 19.5 (17-26) and 36.6 Gy (13-50). During follow-up after radiosurgical treatment, 23 (53.5%) of 43 patients were seizure-free, 10 (23.3%) had significant improvement, were unchanged in 8 (18.6%) and aggravated in 2 (4.6%) patients. In 33 patients, follow-up angiography or MRI was performed. Complete obliteration was achieved in 16 (49.0%) patients, partial obliteration in 13 (39.0%). Four were unchanged (12.0%). Of 33 patients with follow-up performed, 26 were followed for over 2 years. Eleven (84.6%) of 13 patients with complete obliteration were seizure-free (p < 0.005). Four (36.3%) of 13 with partial obliteration and unchanged remained seizure-free. Fifteen patients had experienced intractable seizure before radiosurgery. After radiosurgery, seizures disappeared in 8 (53%) patients. Seizure frequently decreased in 5 (33%) and 2 patients (14%) were unchanged but none was aggravated. Five (71%) of 7 patients with complete obliteration were seizure-free and 2 (40%) of 5 patients with partial obliteration were seizure-free. CONCLUSION Up to now, controversy about resective surgery or radiosurgery as treatment of seizure related to AVMs still remains. In this study, we experienced that Gamma Knife radiosurgery is commonly performed to treat AVMs and can improve symptomatic seizure associated with AVMs. To clarify the mechanism of seizure control in AVMs radiosurgery is difficult, but it seems to be closely related to hemodynamic effects after radiosurgery.
Collapse
Affiliation(s)
- Y J Lim
- Department of Neurosurgery, School of Medicine, Kyung-Hee University, Seoul, Korea.
| | | | | | | | | | | |
Collapse
|
43
|
Abstract
The surgical treatment of epilepsy is expanding in an exciting and unprecedented way. This review highlights some of the recent advances in neuroimaging that have improved epilepsy surgery. In addition, novel therapies currently being evaluated in clinical trials, including gamma knife radiosurgery, deep brain stimulation, and responsive stimulation, are discussed. Further surgical developments that will be ready for human application in the near future are highlighted.
Collapse
Affiliation(s)
- Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, Neurological Institute Room 428, 710 West 168th Street, New York, NY 10032, USA.
| |
Collapse
|
44
|
Régis J, Rey M, Bartolomei F, Vladyka V, Liscak R, Schröttner O, Pendl G. Gamma Knife Surgery in Mesial Temporal Lobe Epilepsy: A Prospective Multicenter Study. Epilepsia 2004; 45:504-15. [PMID: 15101832 DOI: 10.1111/j.0013-9580.2004.07903.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE This article is the first prospective documentation of the efficacy and safety of gamma knife surgery (GKS) in the treatment of drug-resistant epilepsies of mesial temporal lobe origin. METHODS From July 1996 to March 2000, three European centers selected 21 patients with mesial temporal lobe epilepsy (MTLE) for a temporal lobectomy. The preoperative investigations included video-EEG with foramen ovale electrodes, magnetic resonance imaging, neuropsychological testing, and the ESI-55 quality-of-life questionnaire. In place of a cortectomy, radiosurgical treatment was performed by using the Leksell Gamma Knife (LGK) at a dose of 24 +/- 1 Gy at the margin. The target included the anterior parahippocampal cortex and the basal and lateral part of the amygdala and anterior hippocampus (head and body). One patient (a heavy smoker) died of a myocardial infarction. Twenty patients were available for prospective evaluation. A minimum 2-year follow-up period included clinical, neuropsychological, and radiologic evaluations. RESULTS At each 6-month follow-up evaluation, the frequency of seizures was significantly smaller than that at the previous visit. The median seizure frequency of 6.16 the month before treatment was reduced to 0.33 at 2 years after treatment. At 2 years, 65% of the patients (13 of 20) were seizure free. Five patients had transient side effects, including depression, headache, nausea, vomiting, and imbalance. There was no permanent neurological deficit reported except nine visual field deficits. No neuropsychological deterioration was observed 2 years after treatment. The quality of life was significantly better than that before surgery. CONCLUSIONS The safety and efficacy of the radiosurgical treatment of MTLEs appears good in this group of patient over short-to-middle term. Delay of the seizure cessation was the major disadvantage of GKS. A longer follow-up period is required for confirmation of these results.
Collapse
Affiliation(s)
- Jean Régis
- Stereotactic and Functional Neurosurgery Department, Timone Hospital, Marseille (APM), France.
| | | | | | | | | | | | | |
Collapse
|
45
|
Brisman JL, Cole AJ, Cosgrove GR, Thornton AF, Rabinov J, Bussiere M, Bradley-Moore M, Hedley-Whyte T, Chapman PH. Radiosurgery of the Rat Hippocampus: Magnetic Resonance Imaging, Neurophysiological, Histological, and Behavioral Studies. Neurosurgery 2003; 53:951-61; discussion 961-2. [PMID: 14519227 DOI: 10.1227/01.neu.0000083629.92550.a5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2002] [Accepted: 05/27/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To explore the histological, electrophysiological, radiological, and behavioral effects of radiosurgery using a new model of proton beam radiosurgery (PBR) of the rodent hippocampus.
METHODS
Forty-one rats underwent PBR of the right hippocampus with nominal doses of 5 to 130 cobalt Gray equivalents (CGE). Three control animals were untreated. Three months after PBR, 41 animals were evaluated with the Morris water maze, 23 with T2-weighted magnetic resonance imaging, and 22 with intrahippocampal microelectrode recordings. Animals that were studied physiologically were killed, and their brains were examined with Nissl staining and immunocytochemical staining for glutamic acid decarboxylase, heat shock protein 72 (HSP-72), parvalbumin, calmodulin, calretinin, calbindin, and somatostatin.
RESULTS
Ninety and 130 CGE resulted in decreased performance in the Morris water maze, increased signal on T2-weighted magnetic resonance imaging, diminished granule cell field potentials, and tissue necrosis, which was restricted to the irradiated side. These doses also resulted in ipsilateral up-regulation of calbindin and HSP-72. Parvalbumin was down-regulated at 130 CGE. The 30 and 60 CGE animals displayed a marked increase in HSP-72 staining on the irradiated side but no demonstrable cell loss. No asymmetries were noted in somatostatin, calretinin, and glutamic acid decarboxylase staining. Normal physiology was found in rats receiving up to 60 CGE.
CONCLUSION
This study expands our understanding of the effects of radiosurgery on the mammalian brain. Three months after PBR, the irradiated rat hippocampus demonstrates necrosis at 90 CGE, but not at 60 CGE, with associated abnormalities in magnetic resonance imaging, physiology, and memory testing. HSP-72 was up-regulated at nonnecrotic doses.
Collapse
Affiliation(s)
- Jonathan L Brisman
- Neurosurgical Service and Epilepsy Research Laboratory, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Régis J, Bartolomei F, Hayashi M, Chauvel P. Gamma Knife surgery, a neuromodulation therapy in epilepsy surgery! ACTA NEUROCHIRURGICA. SUPPLEMENT 2003; 84:37-47. [PMID: 12379003 DOI: 10.1007/978-3-7091-6117-3_4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The more classical approach for Epilepsy surgery is the removal of the epileptogenic zone (ZE). We present a critical review of information in favor of a possible non-destructive effect of radiosurgery in epilepsy surgery. MATERIAL Clinical material of patients with epilepsies related to a lesion in highly functional areas subjected to radiosurgery with relief of the seizures and no functional worsening is available. We applied direct treatment of the EZ with good efficacy in the absence of destructive aspects on the MR and no functional deterioration (e.g. hypothalamic hamartomas). Experimental studies have shown biochemical differential effect of radiosurgery on the striatum, glial cell elimination, stem cell migration toward the target area, sprouting,... Plasticity phenomenon are induced by radiosurgery when using non necrotizing dosemetry. DISCUSSION There is clinical and experimental evidence of Gamma Knife capability to induce modulation in the neural system. Detailed mechanism of this modulation and dosemetric parameters enabling to induce such plasticity with no necrosis are still unknown. Subpial transection turning out actually to be quite disappointing, there is a specific rationale to test radiosurgery capability to treat EZ cortex while preserving the underlying function of this cortex when the functional risk for cortectomy is too high.
Collapse
Affiliation(s)
- J Régis
- Stereotactic and Functional Neurosurgery Department, Neurophysiology/Neuropsychology INSERM 9926, Timone Hospital, Marseilles, France
| | | | | | | |
Collapse
|
48
|
Hoh BL, Chapman PH, Loeffler JS, Carter BS, Ogilvy CS. Results of Multimodality Treatment for 141 Patients with Brain Arteriovenous Malformations and Seizures: Factors Associated with Seizure Incidence and Seizure Outcomes. Neurosurgery 2002. [DOI: 10.1227/00006123-200208000-00004] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
49
|
Results of Multimodality Treatment for 141 Patients with Brain Arteriovenous Malformations and Seizures: Factors Associated with Seizure Incidence and Seizure Outcomes. Neurosurgery 2002. [DOI: 10.1097/00006123-200208000-00004] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
50
|
Abstract
Arteriovenous malformations of the brain are congenital vascular lesions that affect 0.01-0.50% of the population, and are generally present in patients aged 20-40 years. The usual clinical presentations are haemorrhage, seizures, progressive neurological deficit, or headache. Results of natural history studies have shown a yearly haemorrhage rate of 1-4%. Frequency of rebleeding has increased over the years, and several factors that increase risk of haemorrhage have been identified. Although substantial, the morbidity associated with haemorrhages could be less than previously thought. Over the past decade, great advances have been made in application of endovascular embolisation techniques, stereotactic radiosurgery, and microsurgery, allowing effective multidisciplinary treatment of arteriovenous malformations, including those previously deemed to be untreatable. Increasing attention has been paid to management of flow-related aneurysms associated with these malformations. Finally, many reports of recurrent arteriovenous malformations have coincided with new theories regarding the embryogenesis of these disorders and laboratory work suggesting their proliferative potential.
Collapse
Affiliation(s)
- Ian G Fleetwood
- Department of Neurosurgery and Stanford Stroke Center, Stanford University, Stanford, CA 94305-5327, USA
| | | |
Collapse
|