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Alzate JD, Mashiach E, Bernstein K, De Nigris Vasconcellos F, Qu T, Silverman JS, Shapiro M, Nelson PK, Raz E, Riina HA, Kondziolka D. Quantitative Analysis of Parenchymal Effects and Flow of Large Arteriovenous Malformations Managed With Stereotactic Radiosurgery. Neurosurgery 2023; 93:1057-1065. [PMID: 37235978 DOI: 10.1227/neu.0000000000002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/03/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) of larger arteriovenous malformations (AVM) is associated with an elevated incidence of adverse radiation effects (ARE). To date, volume-response and dose-response models have been used to predict such effects. To understand radiological outcomes and their hemodynamic effects on the regional brain. METHODS A retrospective analysis was conducted at our institution using a prospective registry of patients managed between 2014 and 2020. We included patients with AVM with a nidus larger than 5 cc who received either single-session or volume-staged Gamma Knife radiosurgery. AVM volume changes, volumes of parenchymal response, and obliteration were analyzed and correlated with transit times and diameters of feeding arteries and draining veins. RESULTS Sixteen patients underwent single-session SRS, and 9 patients underwent volume-staged SRS. The average AVM volume was 12.6 cc (5.5-23). The AVM locations were predominantly lobar (80%) and 17 (68%) were in critical locations. The mean margin dose was 17.2 Gy (15-21), and the median V12Gy was 25.5 cc. Fourteen (56%) AVMs had a transit time shorter than 1 second. The median vein-artery ratio (sum diameter of the veins/sum diameter of feeding arteries) was 1.63 (range, 0.60-4.19). Asymptomatic parenchymal effects were detected in 13 (52%) patients and were symptomatic in 4 (16%) patients. The median time to ARE was 12 months (95% CI 7.6-16.4). On univariate analysis, significant predictors of ARE were lower vein-artery ratio ( P = .024), longer transit time ( P = .05), higher mean dose ( P = .028), and higher D95 ( P = .036). CONCLUSION Transit times and vessel diameters are valuable predictors of the subsequent parenchymal response after SRS. A more quantitative understanding of blood flow is critical for predicting the effects on the regional brain after AVM radiosurgery.
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Affiliation(s)
- Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | | | - Tanxia Qu
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | - Maksim Shapiro
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Peter K Nelson
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Eytan Raz
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Howard A Riina
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
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Alzate JD, Mashiach E, Raz E, Shapiro M, Riina H, Kondziolka D. Advances in Radiosurgical Planning: High-Resolution Imaging and Objective Hemodynamic Measurements for Arteriovenous Malformations. World Neurosurg 2023; 178:264-265. [PMID: 37573234 DOI: 10.1016/j.wneu.2023.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Affiliation(s)
- Juan Diego Alzate
- Departments of Neurological Surgery, NYU Langone Health, New York University, New York, New York, USA
| | - Elad Mashiach
- Departments of Neurological Surgery, NYU Langone Health, New York University, New York, New York, USA
| | - Eytan Raz
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York, USA
| | - Maksim Shapiro
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York, USA
| | - Howard Riina
- Departments of Neurological Surgery, NYU Langone Health, New York University, New York, New York, USA; Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York, USA
| | - Douglas Kondziolka
- Departments of Neurological Surgery, NYU Langone Health, New York University, New York, New York, USA
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Daou BJ, Palmateer G, Wilkinson DA, Thompson BG, Maher CO, Chaudhary N, Gemmete JJ, Hayman JA, Lam K, Wahl DR, Kim M, Pandey AS. Radiation-Induced Imaging Changes and Cerebral Edema following Stereotactic Radiosurgery for Brain AVMs. AJNR Am J Neuroradiol 2020; 42:82-87. [PMID: 33214183 DOI: 10.3174/ajnr.a6880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/17/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE T2 signal and FLAIR changes in patients undergoing stereotactic radiosurgery for brain AVMs may occur posttreatment and could result in adverse radiation effects. We aimed to evaluate outcomes in patients with these imaging changes, the frequency and degree of this response, and factors associated with it. MATERIALS AND METHODS Through this retrospective cohort study, consecutive patients treated with stereotactic radiosurgery for brain AVMs who had at least 1 year of follow-up MR imaging were identified. Logistic regression analysis was used to evaluate predictors of outcomes. RESULTS One-hundred-sixty AVMs were treated in 148 patients (mean, 35.6 years of age), including 42 (26.2%) pediatric AVMs. The mean MR imaging follow-up was 56.5 months. The median Spetzler-Martin grade was III. The mean maximal AVM diameter was 2.8 cm, and the mean AVM target volume was 7.4 mL. The median radiation dose was 16.5 Gy. New T2 signal and FLAIR hyperintensity were noted in 40% of AVMs. T2 FLAIR volumes at 3, 6, 12, 18, and 24 months were, respectively, 4.04, 55.47, 56.42, 48.06, and 29.38 mL Radiation-induced neurologic symptoms were encountered in 34.4%. In patients with radiation-induced imaging changes, 69.2% had new neurologic symptoms versus 9.5% of patients with no imaging changes (P = .0001). Imaging changes were significantly associated with new neurologic findings (P < .001). Larger AVM maximal diameter (P = .04) and the presence of multiple feeding arteries (P = .01) were associated with radiation-induced imaging changes. CONCLUSIONS Radiation-induced imaging changes are common following linear particle accelerator-based stereotactic radiosurgery for brain AVMs, appear to peak at 12 months, and are significantly associated with new neurologic findings.
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Affiliation(s)
- B J Daou
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - G Palmateer
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - D A Wilkinson
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - B G Thompson
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - C O Maher
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - N Chaudhary
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.).,Radiology (N.C., J.J.G.)
| | - J J Gemmete
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.).,Radiology (N.C., J.J.G.)
| | - J A Hayman
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - K Lam
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - D R Wahl
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - M Kim
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - A S Pandey
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
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Early detection of cerebral ischemic events on intraoperative magnetic resonance imaging during surgical procedures for deep brain stimulation. Acta Neurochir (Wien) 2019; 161:1545-1558. [PMID: 31053908 DOI: 10.1007/s00701-019-03929-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although intracerebral hemorrhage is the most feared complication of deep brain stimulation (DBS) surgery, cerebral ischemic events in association with DBS surgery have only rarely been described. We therefore evaluated the role of intraoperative MRI (iMRI) for early identification of cerebral ischemic events during DBS procedures and determined how ischemic infarctions affect patients over acute and long-term periods. METHODS Between January 2010 and December 2017, 1160 DBS electrodes were implanted in 595 patients at Chinese People's Liberation Army General Hospital, with the help of iMRI. The iMRI was performed in all patients after implantation, to define the accuracy of lead placement and detect complications. A CT scan was performed on postoperative days 1 to 7. RESULTS The iMRI showed that cerebral ischemic changes happened in nine (1.51% of patients, 0.78% of leads) patients. Only two (0.34%) of nine patients had an ischemic infarction in the basal ganglia, while seven (1.18%) had cortical ischemia. Six (67%) of the nine patients had long-term complications, two with mild hemiparesis, two with seizures, one with language dysfunction, and one with memory loss. Of those with a cortical ischemic infarction, only three (42.86%) of seven patients had no long-term complications. Long-term follow-up imaging showed that not all the patients recovered normal morphological structure in the area of ischemic foci. The factors of sex, age, target, and anesthesia were not related to ischemic events. In six (66.7%) cases, the entry point on the cortex or the path was not ideal. CONCLUSIONS Intraoperative ischemic events are not uncommon in DBS surgery. Ischemia can cause serious permanent complications, and regions subject to severe ischemia cannot be restored; it is therefore necessary to pay careful attention to any signs of ischemia. iMRI objectively provides the basis for early diagnosis of intraoperative ischemic infarction, providing guidance for follow-up treatment. The deviation in the entry point on the cortex or in the path resulted in vascular injury; it may be the key cause of ischemic events during DBS procedures.
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Venous Stenosis and Hemorrhage After Radiosurgery for Cerebral Arteriovenous Malformations. World Neurosurg 2018; 122:e1615-e1625. [PMID: 30500592 DOI: 10.1016/j.wneu.2018.11.193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The risk of hemorrhage remains after radiosurgery for patients with arteriovenous malformations (AVMs), especially during the latency period. The effect of venous outflow stenosis on postradiosurgery AVM hemorrhage has been understudied. The present study sought to clarify the effect of venous stenosis on postradiation hemorrhage. METHODS We retrospectively reviewed the records of patients with AVM seen at our institution from 1990 to 2015. Patients who had undergone radiosurgery were included, and those without sufficient data were excluded. We performed multivariable Cox regression to evaluate the predictors of postradiosurgery hemorrhage, with specific emphasis on venous stenosis. Patients were censored from the first radiosurgery to hemorrhage or the last follow-up visit. The baseline and angiographic characteristics were compared between those with venous stenosis and those without to address potential confounders. RESULTS The present study included 240 patients, of whom 29 (12.1%) had venous stenosis. The venous stenosis cohort included more patients with venous varices (P = 0.009) and fewer with deep venous drainage (P = 0.048) compared with those without venous stenosis. Most patients had grade III or higher AVMs (63.2%), with an obliteration rate of 32.9%. In an all-inclusive multivariable Cox regression, hemorrhage risk was associated with venous stenosis (hazard ratio [HR], 3.70; P = 0.034), age (HR, 1.05; P = 0.002), AVM volume (HR, 1.04; P = 0.004), and hemorrhage before treatment (HR, 4.11; P = 0.014). Male gender was protective (HR, 0.31; P = 0.036) against hemorrhage. CONCLUSIONS We identified statistically significant risk factors for postradiosurgery AVM hemorrhage, which included advanced age, female gender, the presence of venous stenosis, a larger AVM volume, and previous hemorrhage. We recommend cautious selection of patients for radiosurgery with close follow-up after treatment, especially for patients with these risk factors.
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Fennell VS, Martirosyan NL, Atwal GS, Kalani MYS, Spetzler RF, Lemole GM, Dumont T. Effective Surgical Management of Competitive Venous Outflow Restriction After Radiosurgery for Cerebral AVMs: Report of 2 Cases. World Neurosurg 2016; 98:882.e1-882.e7. [PMID: 27838427 DOI: 10.1016/j.wneu.2016.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intracranial arteriovenous malformations (AVMs) are complex pathologies. For patients who do not present with hemorrhage, treatment strategies are often predicated on reducing the risk of hemorrhage and minimizing morbidity. Outcomes vary according to the efficacy of treatment selected. Radiosurgical treatment of certain AVMs can result in incomplete obliteration and may also have only a minimal effect on the presenting nonhemorrhagic symptoms. CASE DESCRIPTIONS We present 2 cases of patients with AVMs who were initially treated with radiosurgery. Both patients' primary clinical symptoms were headaches, which persisted after radiosurgical treatment but abated after subsequent microsurgical resection with or without endovascular embolization. CONCLUSION Venous outflow obstruction is likely a sizable contributive factor in occipital AVMs among patients who present with headaches and symptoms of intracranial hypertension. Because these high-flow lesions may be suboptimally responsive to stereotactic radiosurgery, microsurgical resection, with or without adjunctive endovascular embolization, should be considered as an initial and definitive treatment strategy. Optimal outcomes may be achieved in patients with a visual deficit that is anatomically correlated to their AVMs.
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Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Division of Neurosurgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
| | - G Michael Lemole
- Division of Neurosurgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Travis Dumont
- Division of Neurosurgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
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Kim JW, Chung HT, Han MH, Kim DG, Paek SH. Brain Edema after Repeat Gamma Knife Radiosurgery for a Large Arteriovenous Malformation: A Case Report. Exp Neurobiol 2016; 25:191-6. [PMID: 27574486 PMCID: PMC4999425 DOI: 10.5607/en.2016.25.4.191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/08/2016] [Accepted: 06/16/2016] [Indexed: 11/19/2022] Open
Abstract
Brain edema due to venous thrombosis following stereotactic radiosurgery for a cerebral arteriovenous malformation (AVM) has rarely been reported. We report a patient with a large AVM in the eloquent area, and brain edema developed in this area after repeat Gamma knife stereotactic radiosurgery (GKRS). An 18-year-old female presented with a 4-year-history of persistent headache. Magnetic resonance imaging and transfemoral carotid angiogram revealed a high-flow large AVM in the left parieto-occipital area. Brain edema developed and aggravated patient's symptoms after time-staged GKRS. The cause of edema was thought to be the failure of the surrounding venous channels to drain the venous flow from the normal brain and the drainage was hampered by the persistent shunt flow from the AVM, which was due to the thrombosis of one huge draining vein of the AVM. The microsurgical resection of the AVM nidus eliminated shunt flow and completely normalized the brain edema. Microsurgical resection of the AVM nidus completely normalized the brain edema due to thrombosis of a draining vein of an AVM develops after SRS.
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Affiliation(s)
- Joo Whan Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul 03080, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea
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Morishita T, Okun MS, Burdick A, Jacobson CE, Foote KD. Cerebral venous infarction: a potentially avoidable complication of deep brain stimulation surgery. Neuromodulation 2013; 16:407-13; discussion 413. [PMID: 23738501 DOI: 10.1111/ner.12052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/24/2013] [Accepted: 02/07/2013] [Indexed: 11/29/2022]
Abstract
OBJECT Despite numerous reports on the morbidity and mortality of deep brain stimulation (DBS), cerebral venous infarction has rarely been reported. We present four cases of venous infarct secondary to DBS surgery. METHODS The diagnosis of venous infarction was based on 1) delayed onset of new neurologic deficits on postoperative day 1 or 2; 2) significant edema surrounding the superficial aspect of the implanted lead, with or without subcortical hemorrhage on CT scan. RESULTS Four cases (0.8% per lead, 1.3% per patient) of symptomatic cerebral venous infarction were identified out of 500 DBS lead implantation procedures between July 2002 and August 2009. All four patients had Parkinson's disease. Their DBS leads were implanted in the subthalamic nucleus (n = 2), and the globus pallidus internus (n = 2). Retrospective review of the targeting confirmed that the planned trajectory passed within 3 mm of a cortical vein in two cases for which contrast-enhanced preoperative magnetic resonance (MR) imaging was available. In the other two cases, contrasted targeting images were not obtained preoperatively. CONCLUSION Cerebral venous infarction is a potentially avoidable, but serious complication. To minimize its incidence, we propose the use of high-resolution, contrast-enhanced, T1-weighted MR images to delineate cerebral venous anatomy, along with careful stereotactic planning of the lead trajectory to avoid injury to venous structures.
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Affiliation(s)
- Takashi Morishita
- Department of Neurosurgery, University of Florida College of Medicine/Shands Hospital, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
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Zacharia BE, Bruce S, Appelboom G, Connolly ES. Occlusive Hyperemia Versus Normal Perfusion Pressure Breakthrough after Treatment of Cranial Arteriovenous Malformations. Neurosurg Clin N Am 2012; 23:147-51. [DOI: 10.1016/j.nec.2011.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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10
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Affiliation(s)
- Hamad I Farhat
- Department of Neurological Surgery, NorthShore University HealthSystem, University of Chicago Medical Center, Chicago, Illinois, USA
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Hayhurst C, Monsalves E, van Prooijen M, Cusimano M, Tsao M, Menard C, Kulkarni AV, Schwartz M, Zadeh G. Pretreatment predictors of adverse radiation effects after radiosurgery for arteriovenous malformation. Int J Radiat Oncol Biol Phys 2011; 82:803-8. [PMID: 21345621 DOI: 10.1016/j.ijrobp.2010.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 11/24/2010] [Accepted: 12/03/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE To identify vascular and dosimetric predictors of symptomatic T2 signal change and adverse radiation effects after radiosurgery for arteriovenous malformation, in order to define and validate preexisting risk models. METHODS AND MATERIALS A total of 125 patients with arteriovenous malformations (AVM) were treated at our institution between 2005 and 2009. Eighty-five patients have at least 12 months of clinical and radiological follow-up. Any new-onset headaches, new or worsening seizures, or neurological deficit were considered adverse events. Follow-up magnetic resonance images were assessed for new onset T2 signal change and the volume calculated. Pretreatment characteristics and dosimetric variables were analyzed to identify predictors of adverse radiation effects. RESULTS There were 19 children and 66 adults in the study cohort, with a mean age of 34 (range 6-74). Twenty-three (27%) patients suffered adverse radiation effects (ARE), 9 patients with permanent neurological deficit (10.6%). Of these, 5 developed fixed visual field deficits. Target volume and 12 Gy volume were the most significant predictors of adverse radiation effects on univariate analysis (p < 0.001). Location and cortical eloquence were not significantly associated with the development of adverse events (p = 0.12). No additional vascular parameters were identified as predictive of ARE. There was a significant target volume threshold of 4 cm(3), above which the rate of ARE increased dramatically. Multivariate analysis target volume and the absence of prior hemorrhage are the only significant predictors of ARE. The volume of T2 signal change correlates to ARE, but only target volume is predictive of a higher volume of T2 signal change. CONCLUSIONS Target volume and the absence of prior hemorrhage is the most accurate predictor of adverse radiation effects and complications after radiosurgery for AVMs. A high percentage of permanent visual field defects in this series suggest the optic radiation is a critical radiosensitive structure.
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Affiliation(s)
- Caroline Hayhurst
- Gamma Knife Unit, Division of Neurosurgery, University Health Network, Toronto, Canada
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Yen CP, Khaled MA, Schwyzer L, Vorsic M, Dumont AS, Steiner L. Early Draining Vein Occlusion After Gamma Knife Surgery for Arteriovenous Malformations. Neurosurgery 2010; 67:1293-302; discussion 1302. [DOI: 10.1227/neu.0b013e3181f2b396] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Increased signals on T2-weighted magnetic resonance imaging usually interpreted as radiation-induced changes or brain edema is a common short- to mid-term complication after Gamma Knife surgery (GKS) for intracranial arteriovenous malformations (AVMs), although its nature remains to be clarified. Early draining vein occlusion with resultant brain edema or hemorrhage, although well established in surgical series, was not described in radiosurgical literature until recently.
OBJECTIVE:
To outline the incidence, clinical manifestations, and outcomes of this unusual complication in our series of 1256 AVM patients treated with GKS.
METHODS:
From 1989 to 2008, 1400 patients underwent GKS for cerebral AVMs or dural arteriovenous fistulae at the University of Virginia. In 1256 patients, magnetic resonance imaging after GKS was available for analysis of radiation-induced changes and early draining vein occlusion.
RESULTS:
After GKS, 456 patients (36%) developed radiation-induced changes surrounding the treated nidi. Among these patients, 12 had early thrombosis of the draining vein accompanied by radiation-induced changes. Venous thrombosis occurred 6 to 25 months (median 11.6 months) after GKS. Three patients were asymptomatic on the image findings of venous occlusion and brain edema, 3 experienced headache, 1 had seizure and headache, and neurological deficits developed in 5. Patients with neurological deficits were treated with corticosteroids; 2 of the patients recovered completely, 1 still had slight hemiparesis, 1 had short-term memory deficits, and 1 died of massive intracerebral hemorrhage.
CONCLUSION:
Although venous structures are considered more radioresistant, endothelial damage accompanied by venous flow stasis might cause early venous thrombosis and premature venous occlusion after radiosurgery for AVMs. In our series, all patients had a favorable outcome except 1 with a fatal hemorrhage.
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Affiliation(s)
- Chun-Po Yen
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Mohamad A Khaled
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Lucia Schwyzer
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Matjaz Vorsic
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Aaron S Dumont
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
| | - Ladislau Steiner
- Lars Leksell Center for Gamma Surgery, Department of Neurosurgical Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
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van den Berg R, Buis DR, Lagerwaard FJ, Lycklama à Nijeholt GJ, Vandertop WP. Extensive white matter changes after stereotactic radiosurgery for brain arteriovenous malformations: a prognostic sign for obliteration? Neurosurgery 2009; 63:1064-9; discussion 1069-70. [PMID: 19008768 DOI: 10.1227/01.neu.0000330413.73983.02] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Perinidal high-signal-intensity changes on T2-weighted magnetic resonance imaging can be seen surrounding radiosurgically treated brain arteriovenous malformations (AVM). Occasionally, these signal intensity changes develop far beyond the irradiated volume. A retrospective analysis of both the pre- and postradiosurgery magnetic resonance imaging and angiographic studies was performed to analyze the cause of these extensive perinidal white matter changes. METHODS The pre- and postradiosurgical magnetic resonance imaging and angiographic studies of 30 patients with T2 high-signal-intensity changes surrounding a brain AVM were analyzed retrospectively. Patients were divided into 2 groups on the basis of the extension of the signal intensity changes within or beyond the 10-Gy isodose area. The angiographic analysis was focused on the venous drainage pattern (deep versus superficial), venous stenosis, and the number of draining veins before and after radiosurgery. In addition, the obliteration rate was determined for the 2 subgroups. RESULTS Fourteen patients (47%) showed high-signal-intensity changes far beyond the 10-Gy isodose area. A single draining vein was more often present in these patients with extensive T2 hyperintensity signal changes than in the other group. Obliteration was achieved in 12 (88%) of 14 patients with extensive signal intensity changes, as opposed to 8 (50%) of 16 patients in the other group. CONCLUSION High-signal-intensity changes after radiosurgery for brain AVMs, far beyond the 10-Gy isodose area on T2-weighted images, are especially seen in brain AVMs draining through a single vein. The higher occlusion rate of brain AVMs under these circumstances is well appreciated.
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Affiliation(s)
- René van den Berg
- Department of Radiology, Free University Medical Center, Amsterdam, The Netherlands.
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Ganz JC, Reda WA, Abdelkarim K, Hafez A. A simple method for predicting imaging-based complications following gamma knife surgery for cerebral arteriovenous malformations. J Neurosurg 2005; 102 Suppl:4-7. [PMID: 15662771 DOI: 10.3171/jns.2005.102.s_supplement.0004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object.The authors studied the relationship between dose planning parameters and complications in the treatment of cerebral arteriovenous malformations (AVMs).Methods.There were 41 continuous unselected patients. The mean follow-up period was 19 months; the mean age was 28 years; the male/female ratio was 2.2:1.0; the median prescription dose was 25 Gy (range 14–25 Gy); the median prescription isodose was 50%. The median lesion volume was 4.4 cm3. The median lesion coverage was 93%; and the mean conformity index was 1.22.The authors found no relationship between lesion volume or integral dose and the development of the clinical effects based on the adverse radiation effects (AREs); however, there was a significant relationship between both target volume and integral dose with the development of AREs as well as the severity of the AREs.Conclusions.The integral dose could be used as a guideline for the prescription dose. Arguments are made for maximizing the prescription dose for the long-term safety of the patient.
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Ganz JC, Reda WA, Abdelkarim K, Hafez A. A simple method for predicting imaging-based complications following gamma knife surgery for cerebral arteriovenous malformations. J Neurosurg 2005. [DOI: 10.3171/sup.2005.102.s_supplement.0004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The authors studied the relationship between dose planning parameters and complications in the treatment of cerebral arteriovenous malformations (AVMs).
Methods. There were 41 continuous unselected patients. The mean follow-up period was 19 months; the mean age was 28 years; the male/female ratio was 2.2:1.0; the median prescription dose was 25 Gy (range 14–25 Gy); the median prescription isodose was 50%. The median lesion volume was 4.4 cm3. The median lesion coverage was 93%; and the mean conformity index was 1.22.
The authors found no relationship between lesion volume or integral dose and the development of the clinical effects based on the adverse radiation effects (AREs); however, there was a significant relationship between both target volume and integral dose with the development of AREs as well as the severity of the AREs.
Conclusions. The integral dose could be used as a guideline for the prescription dose. Arguments are made for maximizing the prescription dose for the long-term safety of the patient.
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