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Maroufi SF, Habibi MA, Mirjani MS, Molla A, Pabarja N, Mehmandoost M, Sheehan JP, Iranmehr A. Repeat single-session stereotactic radiosurgery for arteriovenous malformation: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:203. [PMID: 38702494 DOI: 10.1007/s10143-024-02438-5] [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: 02/07/2024] [Revised: 03/20/2024] [Accepted: 04/27/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Stereotactic radiosurgery is the preferred option for treating brain arteriovenous malformation (AVM) when the risks associated with surgery outweigh the potential benefits. However, some patients require repeat radiosurgery due to residual AVM after the first procedure. This systematic review and meta-analysis aimed to investigate the safety and efficacy of repeated procedure of radiosurgery for AVM. METHOD A systematic review was conducted according to the PRISMA guideline. The search was conducted on PubMed, Scopus, Embase, and Web of Science, using a pre-designed search string. Studies investigating the efficacy of repeat radiosurgery for residual AVM following initial single session radiosurgery were included. The risk of bias was assessed using the JBI tool. Meta-analysis and met-regression were performed to pool and inspect data. RESULTS Our meta-analysis, with a mean follow-up of 45.57 months, reveals repeat radiosurgery as a viable option for arteriovenous malformations (AVMs), achieving a 60.82% obliteration rate with a mean time to obliteration of 33.18 months. Meta-regression identifies AVM volume and Spetzler-Martin (SM) grade as factors influencing obliteration, with smaller volume and lower SM grades associated with higher rates. Complications include 10.33% radiation-induced changes, 5.26% post-radiosurgery hemorrhage, 2.56% neurologic deficits, and 0.67% cyst formation. Heterogeneity in complications is primarily attributed to male proportion and SM grade, while factors influencing post-radiosurgery hemorrhage remain unclear. The type of radiosurgery, whether Gamma Knife Radiosurgery (GKRS) or LINAC, does not significantly impact outcomes. CONCLUSION Repeat radiosurgery is a feasible, effective, and safe treatment for AVMs following failure of initial radiosurgery. When utilized in appropriate patient subgroups, it provides an acceptable risk-to-benefit profile. Feature studies are required to clarify its clear indications.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ayoob Molla
- School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Nafise Pabarja
- Student Research Committee, Qom University of Medical Sciences, Qom, Iran
| | - Mahdi Mehmandoost
- Student's Scientific Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
| | - Arad Iranmehr
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Gamma Knife Radiosurgery Centre, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Pikis S, Mantziaris G, Protopapa M, Shaaban A, Sheehan JP. Single-Session Stereotactic Radiosurgery After Failed Repeat Radiosurgery for Cerebral Arteriovenous Malformations. World Neurosurg 2024; 184:334. [PMID: 38368153 DOI: 10.1016/j.wneu.2024.01.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA; Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece; Neurosurgery, Apostolos Loukas Medical Center, Nicosia, Cyprus
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Maria Protopapa
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Pikis S, Mantziaris G, Dumot C, Shaaban A, Protopapa M, Xu Z, Niranjan A, Wei Z, Srinivasan P, Tang LW, Liscak R, May J, Martinez Moreno N, Martinez Álvarez R, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Elazzazi AH, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Lunsford D, Sheehan JP. Third Stereotactic Radiosurgery for Residual Arteriovenous Malformations: A Retrospective Multicenter Study. Neurosurgery 2023:00006123-990000000-01004. [PMID: 38108313 DOI: 10.1227/neu.0000000000002805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no studies evaluating the efficacy and safety of more than 2 stereotactic radiosurgery (SRS) procedures for cerebral arteriovenous malformations (AVM). The aim of this study was to provide evidence on the role of third single-session SRS for AVM residual. METHODS This multicenter, retrospective study included patients managed with a third single-session SRS procedure for an AVM residual. The primary study outcome was defined as AVM nidus obliteration without AVM bleeding or symptomatic radiation-induced changes (RIC). Secondary outcomes evaluated were AVM obliteration, AVM hemorrhage, asymptomatic, and symptomatic RIC. RESULTS Thirty-eight patients (20/38 [52.6%] females, median age at third SRS 34.5 [IQR 20] years) were included. The median clinical follow-up was 46 (IQR 14.8) months, and 17/38 (44.7%) patients achieved favorable outcome. The 3-year and 5-year cumulative probability rates of favorable outcome were 23% (95% CI = 10%-38%) and 53% (95% CI = 29%-73%), respectively. The cumulative probability of AVM obliteration at 3 and 5 years after the third SRS was 23% (95% CI = 10%-37%) and 54% (95% CI = 29%-74%), respectively. AVM bleeding occurred in 2 patients, and 1 of them underwent subsequent resection. The cumulative probability rate of post-SRS AVM hemorrhage remained constant at 5.3% (95% CI = 1%-16%) during the first 5 years of follow-up. Transient symptomatic RIC managed conservatively occurred in 5/38 patients (13.2%) at a median time of 12.5 (IQR 22.5) months from third SRS. Radiation-induced cyst formation was noted in 1 patient (4.2%) 19 months post-SRS. No mortality, radiation-associated malignancy, or permanent symptomatic RIC was noted during follow-up. CONCLUSION A third single-session SRS to treat a residual intracranial AVM offers obliteration in most patients. The risk of RIC was low, and these effects were transient. While not often required, a third SRS can be performed in patients with persistent residual AVMs.
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Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
| | - Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Maria Protopapa
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Priyanka Srinivasan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lilly W Tang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Hesham Elazzazi
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Francis J Jareczek
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James McInerney
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Sasagasako T, Mori H, Hattori EY, Ikedo T, Hamano E, Shimonaga K, Kushi Y, Iihara K, Kataoka H. Radiation-Induced Changes Associated with Obliteration of Brain AVMs after Repeat Radiosurgery. AJNR Am J Neuroradiol 2023; 44:143-149. [PMID: 36702500 PMCID: PMC9891338 DOI: 10.3174/ajnr.a7772] [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: 08/26/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Radiation-induced changes can occur after stereotactic radiosurgery for brain AVMs, potentially causing symptomatic complications. We evaluated the incidence of such changes and the efficacy of repeat gamma knife radiosurgery for incompletely obliterated AVMs. MATERIALS AND METHODS We retrospectively evaluated 150 patients who underwent gamma knife radiosurgery for AVMs between 2002 and 2020; twenty-five underwent further radiosurgical procedures for incompletely obliterated AVMs. We recorded the median margin doses at the first (median, 20 Gy; range, 12-23 Gy; AVM volume, 0.026-31.3 mL) and subsequent procedures (median, 18 Gy; range, 12-23 Gy; AVM volume, 0.048-9.2 mL). RESULTS After the first treatment, radiologic radiation-induced changes developed in 48 (32%) patients, eight of whom had symptomatic changes. After repeat gamma knife radiosurgery, 16 of 25 patients achieved complete AVM obliteration (64%). The development of radiation-induced changes after the first treatment was significantly associated with successful obliteration by subsequent radiosurgery (OR = 24.0, 95% CI 1.20-483, P = .007). Radiation-induced changes occurred in only 5 (20%) patients who underwent a second gamma knife radiosurgery, one of whom experienced transient neurologic deficits. Between the first and repeat gamma knife radiosurgery procedures, there was no significant difference in radiologic and symptomatic radiation-induced changes (P = .35 and P = 1.0, respectively). CONCLUSIONS Radiation-induced changes after the first gamma knife radiosurgery were associated with AVM obliteration after a repeat procedure. The risk of symptomatic radiation-induced changes did not increase with retreatment. When the first procedure fails to achieve complete AVM obliteration, a favorable outcome can be achieved by a repeat gamma knife radiosurgery, even if radiation-induced changes occur after the first treatment.
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Affiliation(s)
- T Sasagasako
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - H Mori
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - E Y Hattori
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - T Ikedo
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - E Hamano
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Shimonaga
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Y Kushi
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Iihara
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - H Kataoka
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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5
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Pikis S, Mantziaris G, Ramanathan P, Xu Z, Sheehan JP. Repeat stereotactic radiosurgery for cerebral arteriovenous malformations. Neurosurg Focus 2022; 53:E11. [DOI: 10.3171/2022.4.focus2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The purpose of this retrospective, single-institution study was to evaluate radiological and clinical outcomes of patients managed with repeat stereotactic radiosurgery (SRS) for residual cerebral arteriovenous malformation (AVM) after prior SRS.
METHODS
The authors evaluated the clinical and radiological outcomes of consecutive patients treated with repeat single-session SRS for a residual brain AVM from 1989 to 2021.
RESULTS
In total, 170 patients underwent repeat SRS for AVM (90 [52.9%] females; median [interquartile range] age at the first SRS procedure 28 [21.5] years; median [interquartile range] age at the second SRS procedure 32 [22.5] years). After repeat SRS, the actuarial 3-, 5-, and 10-year AVM obliteration rates were 37.6%, 57.3%, and 80.9%, respectively. Higher obliteration rates were associated with margin dose ≥ 19 Gy (p = 0.001). After the second SRS procedure, hemorrhage occurred in 8.2% of patients and was lethal in 1 patient. The risk factors of intracranial hemorrhage were age < 18 years (p = 0.03) and residual AVM diameter > 20 mm (p = 0.004). Lower obliteration rates were noted in patients with residual AVM diameter > 20 mm (p = 0.04) and those < 18 years of age (p = 0.04). Asymptomatic, symptomatic, and permanent radiation-induced changes (RICs) after the second SRS procedure occurred in 25.9%, 8.8%, and 5.3% of patients, respectively, and were associated with RIC after the first SRS procedure (p = 0.006). There was 1 case of a radiation-induced meningioma 12 years after SRS.
CONCLUSIONS
Repeat SRS is a reasonable therapeutic option, in particular for patients with residual AVM. Repeat SRS was associated with more favorable outcomes in adult patients and those with residual AVM smaller than 20 mm in maximum diameter. To increase the rate of residual AVM obliteration, a prescription dose ≥ 19 Gy should ideally be used for repeat SRS.
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Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Purushotham Ramanathan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Capitanio JF, Panni P, Gallotti AL, Gigliotti CR, Scomazzoni F, Acerno S, Del Vecchio A, Mortini P. Radiosurgical treatment of arteriovenous malformations in a retrospective study group of 33 children: the importance of radiobiological scores. Childs Nerv Syst 2019; 35:301-308. [PMID: 30474715 DOI: 10.1007/s00381-018-4008-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Arteriovenous malformations' (AVMs) obliteration depends on several factors; among the many factors that must be considered to obtain a high rate of obliteration and a low rate of complications, Flickinger-Pollock Score (FPS) seems to have an important role but still have to be validated in the pediatric population while Paddick-Conformity Index (PCI) still has no demonstration of its utility on the outcome and is considered only as a treatment quality marker. METHODS We retrospectively analyzed 33 consecutive children (2-18 years) with an AVM, treated with stereotactic radiosurgery Gamma Knife (SRS-GK) from 2001 to 2014 in our institution. We assess angiographic (DSA) Obliteration Rate (OR) as well FPS and PCI to draw conclusions. RESULTS DSA-OR was 60.6% with a rate of hemorrhage of 0%. median target volume (TV) was 3.60 cc (mean 4.32 ± 3.63; range 0.15-14.2), median PD was 22 Gy (mean 21.4 ± 2.6; range 16.5-25). Median percentage of coverage was 98% (mean 97 ± 3; range 84-100). The median modified FPS was 0.78 (mean 0.89 ± 0.52; range 0.21-2.1) and highly correlate with OR (p = 0.01). The median PCI was 0.65 (mean 0.65 ± 0.14; range 0.34-0.95) A PCI lower than 0.57 highly correlates with final OR (p = 0.02). CONCLUSION SRS-GK was safe and gradually effective in children. A prescription dose-like that used in adult population (i.e. > 18 and between 20 and 25 Gy) is essential to achieve obliteration. A PD of 23 Gy and 22 Gy did impact OR, respectively (p = 0.02) and (p = 0.05). FPS and PCI are valuable scores that seem to correlate with the OR also in the pediatric population although further prospective studies are needed to confirm these observations.
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Affiliation(s)
- Jody Filippo Capitanio
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Pietro Panni
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Luigi Gallotti
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen Rosaria Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesco Scomazzoni
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefania Acerno
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Lenck S, Schwartz M, Hengwei J, Agid R, Nicholson P, Krings T, Tymianski M, Mendes-Pereira V, Radovanovic I. Management of Residual Brain Arteriovenous Malformations After Stereotactic Radiosurgery. World Neurosurg 2018; 116:e1105-e1113. [DOI: 10.1016/j.wneu.2018.05.180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 11/29/2022]
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8
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Dohm A, McTyre ER, Okoukoni C, Henson A, Cramer CK, LeCompte MC, Ruiz J, Munley MT, Qasem S, Lo HW, Xing F, Watabe K, Laxton AW, Tatter SB, Chan MD. Staged Stereotactic Radiosurgery for Large Brain Metastases: Local Control and Clinical Outcomes of a One-Two Punch Technique. Neurosurgery 2018; 83:114-121. [PMID: 28973432 DOI: 10.1093/neuros/nyx355] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 06/11/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Treatment options are limited for large, unresectable brain metastases. OBJECTIVE To report a single institution series of staged stereotactic radiosurgery (SRS) that allows for tumor response between treatments in order to optimize the therapeutic ratio. METHODS Patients were treated with staged SRS separated by 1 mo with a median dose at first SRS of 15 Gy (range 10-21 Gy) and a median dose at second SRS of 14 Gy (range 10-18 Gy). Overall survival was evaluated using the Kaplan-Meier method. Cumulative incidences were estimated for neurological death, radiation necrosis, local failure (marginal or central), and distant brain failure. Absolute cumulative dose-volume histogram was created for each treated lesion. Logistic regression and competing risks regression were performed for each discrete dose received by a certain volume. RESULTS Thirty-three patients with 39 lesions were treated with staged radiosurgery. Overall survival at 6 and 12 mo was 65.0% and 60.0%, respectively. Cumulative incidence of local failure at 6 and 12 mo was 3.2% and 13.3%, respectively. Of the patients who received staged therapy, 4 of 33 experienced local failure. Radiation necrosis was seen in 4 of 39 lesions. Two of 33 patients experienced a Radiation Therapy Oncology Group toxicity grade > 2 (2 patients had grade 4 toxicities). Dosimetric analysis revealed that dose (Gy) received by volume of brain (ie, VDose(Gy)) was associated with radiation necrosis, including the range V44.5Gy to V87.8Gy. CONCLUSION Staged radiosurgery is a safe and effective option for large, unresectable brain metastases. Prospective studies are required to validate the findings in this study.
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Affiliation(s)
- Ammoren Dohm
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emory R McTyre
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine Okoukoni
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrianna Henson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christina K Cramer
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael C LeCompte
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jimmy Ruiz
- Department of Medicine (Hematology and Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Shadi Qasem
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Fei Xing
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kounosuke Watabe
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adrian W Laxton
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Stephen B Tatter
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael D Chan
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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9
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Marciscano AE, Huang J, Tamargo RJ, Hu C, Khattab MH, Aggarwal S, Lim M, Redmond KJ, Rigamonti D, Kleinberg LR. Long-term Outcomes With Planned Multistage Reduced Dose Repeat Stereotactic Radiosurgery for Treatment of Inoperable High-Grade Arteriovenous Malformations: An Observational Retrospective Cohort Study. Neurosurgery 2018; 81:136-146. [PMID: 28201783 DOI: 10.1093/neuros/nyw041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/12/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). OBJECTIVE To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs. METHODS Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected. RESULTS Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated ( P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year. CONCLUSION Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.
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Affiliation(s)
- Ariel E Marciscano
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- 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
| | - Chen Hu
- Department of Oncology, Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamed H Khattab
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sameer Aggarwal
- The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Ding D, Starke RM, Sheehan JP. Radiosurgery for the management of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:69-83. [PMID: 28552160 DOI: 10.1016/b978-0-444-63640-9.00007-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare, unstable vascular lesions which spontaneously rupture at a rate of approximately 2-4% annually. Stereotactic radiosurgery is a minimally invasive treatment for AVMs, with a favorable risk-to-benefit profile in most patients, with respect to obliteration, hemorrhage, and seizure control. Radiosurgery is ideally suited for small to medium-sized AVMs (diameter <3cm or volume <12cm3) located in deep or eloquent brain regions. Obliteration is ultimately achieved in 70-80% of cases and is directly associated with nidus volume and radiosurgical margin dose. Adverse radiation effects, which appear as T2-weighted hyperintensities on magnetic resonance imaging, develop in 30-40% of patients after AVM radiosurgery, are symptomatic in 10%, and fail to clinically resolve in 2-3%. The risk of AVM hemorrhage may be reduced by radiosurgery, but the hemorrhage risk persists during the latency period between treatment and obliteration. Delayed postradiosurgery cyst formation occurs in 2% of cases and may require surgical treatment. Radiosurgery abolishes or ameliorates seizure activity in the majority of patients with AVM-associated epilepsy and induces de novo seizures in 1-2% of those without preoperative seizures. Strategies for the treatment of large-volume AVMs include neoadjuvant embolization and either dose- or volume-staged radiosurgery.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
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12
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Ding D, Xu Z, Shih HH, Starke RM, Yen CP, Cohen-Inbar O, Sheehan JP. Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2016; 79:690-700. [DOI: 10.1227/neu.0000000000001409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Incompletely obliterated cerebral arteriovenous malformations (AVMs) after initial treatment with stereotactic radiosurgery (SRS) can be treated with a repeat session of SRS. However, the relative efficacy of repeat vs initial SRS is not well specified.
OBJECTIVE:
To retrospectively compare in matched cohorts the outcomes of repeat vs initial SRS for the treatment of matched cohorts with angioarchitecturally similar AVMs.
METHODS:
We studied a data set of patients with AVM treated with radiosurgery during the period spanning 1989 to 2013. Patients with AVM who underwent repeat SRS with radiologic follow-up of ≥2 years or nidus obliteration were identified for the study and matched, in a 1:1 fashion that was blinded to outcome, to patients with previously untreated AVMs who underwent initial SRS. Statistical analyses were performed to compare the outcomes after repeat vs initial SRS.
RESULTS:
The matching approach resulted in 84 patients for the repeat and the initial SRS cohort (mean margin doses, 20.7 and 20.9 Gy, respectively; P =.74). In the repeat SRS cohort, obliteration was achieved in 67%; the radiologic, symptomatic, and permanent radiation-induced change rates were 35%, 10%, and 4%, respectively; and the post-SRS hemorrhage rate was 3.1%/y. Compared with the initial SRS cohort, the repeat SRS cohort had significantly lower obliteration rates (P =.04) and higher post-SRS hemorrhage rates (P =.04). The radiation-induced change rates of the 2 cohorts were not significantly different.
CONCLUSION:
Repeat SRS yields considerably poorer outcomes than initial SRS for angioarchitecturally comparable AVMs. Further studies in AVM radiobiology and vascular structure are necessary to elucidate this potentially differential response.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Han-Hsun Shih
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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13
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Microsurgical Resection for Persistent Arteriovenous Malformations Following Gamma Knife Radiosurgery: A Case-Control Study. World Neurosurg 2016; 88:277-288. [DOI: 10.1016/j.wneu.2016.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/04/2016] [Accepted: 01/04/2016] [Indexed: 11/21/2022]
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14
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Lee CC, Reardon MA, Ball BZ, Chen CJ, Yen CP, Xu Z, Wintermark M, Sheehan J. The predictive value of magnetic resonance imaging in evaluating intracranial arteriovenous malformation obliteration after stereotactic radiosurgery. J Neurosurg 2015; 123:136-44. [DOI: 10.3171/2014.10.jns141565] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The current gold standard for diagnosing arteriovenous malformation (AVM) and assessing its obliteration after stereotactic radiosurgery (SRS) is digital subtraction angiography (DSA). Recently, MRI and MR angiography (MRA) have become increasingly popular imaging modalities for the follow-up of patients with an AVM because of their convenient setup and noninvasiveness. In this study, the authors assessed the sensitivity and specificity of MRI/MRA in evaluating AVM nidus obliteration as assessed by DSA.
METHODS
The authors study a consecutive series of 136 patients who underwent SRS between January 2000 and December 2012 and who underwent regular clinical examinations, several MRI studies, and at least 1 post-SRS DSA follow- up evaluation at the University of Virginia. The average follow-up time was 47.3 months (range 10.1–165.2 months). Two blinded observers were enrolled to interpret the results of MRI/MRA compared with those of DSA. The sensitivity, specificity, positive predictive value, and negative predictive value for the obliteration of AVM were reported.
RESULTS
On the basis of DSA, 73 patients (53.7%) achieved final angiographic obliteration in a median of 28.8 months. The sensitivity (the probability of finding obliteration on MRI/MRA among those for whom complete obliteration was shown on DSA) was 84.9% for one observer (Observer 1) and 76.7% for the other (Observer 2). The specificity was 88.9% and 95.2%, respectively. The false-negative interpretations were significantly related to the presence of draining veins, perinidal edema on T2-weighted images, and the interval between the MRI/MRA and DSA studies.
CONCLUSIONS
MRI/MRA predicted AVM obliteration after SRS in most patients and can be used in their follow-up. However, because the specificity of MRI/MRA is not perfect, DSA should still be performed to confirm AVM nidus obliteration after SRS.
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Affiliation(s)
- Cheng-Chia Lee
- Departments of 1Neurological Surgery,
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 5School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; and
| | - Michael A. Reardon
- 3Radiology & Medical Imaging, Neuroradiology Division, University of Virginia Health System, Charlottesville, Virginia
| | | | | | | | | | - Max Wintermark
- 6Department of Radiology, Stanford University, Palo Alto, California
| | - Jason Sheehan
- Departments of 1Neurological Surgery,
- 2Radiation Oncology, and
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15
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Moraes PL, Dias RS, Weltman E, Giordani AJ, Benabou S, Segreto HRC, Segreto RA. Outcome of cerebral arteriovenous malformations after linear accelerator reirradiation. Surg Neurol Int 2015; 6:96. [PMID: 26110078 PMCID: PMC4462616 DOI: 10.4103/2152-7806.158205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/05/2015] [Indexed: 12/02/2022] Open
Abstract
Background: The aim of this study was to evaluate the clinical outcome of patients undergoing single-dose reirradiation using the Linear Accelerator (LINAC) for brain arteriovenous malformations (AVM). Methods: A retrospective study of 37 patients with brain AVM undergoing LINAC reirradiation between April 2003 and November 2011 was carried out. Patient characteristics, for example, gender, age, use of medications, and comorbidities; disease characteristics, for example, Spetzler–Martin grading system, location, volume, modified Pollock–Flickinger score; and treatment characteristics, for example, embolization, prescription dose, radiation dose–volume curves, and conformity index were analyzed. During the follow-up period, imaging studies were performed to evaluate changes after treatment and AVM cure. Complications, such as edema, rupture of the blood–brain barrier, and radionecrosis were classified as symptomatic and asymptomatic. Results: Twenty-seven patients underwent angiogram after reirradiation and the percentage of angiographic occlusion was 55.5%. In three patients without obliteration, AVM shrinkage made it possible to perform surgical resection with a 2/3 cure rate. A reduction in AVM nidus volume greater than 50% after the first procedure was shown to be the most important predictor of obliteration. Another factor associated with AVM cure was a prescription dose higher than 15.5 Gy in the first radiosurgery. Two patients had permanent neurologic deficits. Factors correlated with complications were the prescription dose and maximum dose in the first procedure. Conclusion: This study suggests that single-dose reirradiation is safe and feasible in partially occluded AVM. Reirradiation may not benefit candidates whose prescribed dose was lower than 15.5 Gy in the first procedure and initial AVM nidus volume did not decrease by more than 50% before reirradiation.
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Affiliation(s)
- Paulo L Moraes
- Serviço de Radioterapia do Hospital São Joaquim - Beneficência Portuguesa de São Paulo and Universidade Federal de São Paulo/Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, S.P., Brazil
| | - Rodrigo S Dias
- Universidade Federal de São Paulo/Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, S.P., Brazil
| | - Eduardo Weltman
- Hospital Israelita Albert Einstein, and Faculdade de Medicina da Universidade de São Paulo, São Paulo, S.P., Brazil
| | - Adelmo J Giordani
- Universidade Federal de São Paulo/Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, S.P., Brazil
| | - Salomon Benabou
- Serviço de Radioterapia e Radiocirurgia do Hospital Bandeirantes, São Paulo, S.P., Brazil
| | - Helena R C Segreto
- Universidade Federal de São Paulo/Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, S.P., Brazil
| | - Roberto A Segreto
- Universidade Federal de São Paulo/Escola Paulista de Medicina - UNIFESP/EPM, São Paulo, S.P., Brazil
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16
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Awad AJ, Walcott BP, Stapleton CJ, Ding D, Leed CC, Loeffler JS. Repeat radiosurgery for cerebral arteriovenous malformations. J Clin Neurosci 2015; 22:945-950. [PMID: 25913746 DOI: 10.1016/j.jocn.2015.01.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/30/2014] [Accepted: 01/01/2015] [Indexed: 10/23/2022]
Abstract
We perform a systematic review of repeat radiosurgery for cerebral arteriovenous malformations (AVM) with an emphasis on lesion obliteration rates and complications. Radiosurgery is an accepted treatment modality for AVM located in eloquent cortex or deep brain structures. For residual or persistent lesions, repeat radiosurgery can be considered if sufficient time has passed to allow for a full appreciation of treatment effects, usually at least 3years. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. References for this review were identified by searches of MEDLINE, Web of Science and Google Scholar databases. A total of 14 studies comprising 733 patients met the review criteria and were included. For series that reported target dose at both first and repeat treatments, the weighted means were 19.42Gy and 19.06Gy, respectively. The mean and median obliteration rate for the repeat radiosurgery treatments were 61% (95% confidence interval 51.9-71.7%) and 61.5%, respectively. The median follow up following radiosurgery ranged from 19.5 to 80months. Time to complete obliteration after the repeat treatment ranged from 21 to 40.8months. The most common complications of repeat radiosurgery for AVM included hemorrhage (7.6%) and radiation-induced changes (7.4%). Repeat radiosurgery can be used to treat incompletely obliterated AVM with an obliteration rate of 61%. Complications are related to treatment effect latency (hemorrhage risk) as well as radiation-induced changes. Repeat radiosurgery can be performed at 3 years following the initial treatment, allowing for full realization of effects from the initial treatment prior to commencing therapy.
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Affiliation(s)
- Ahmed J Awad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Brian P Walcott
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Cheng-Chia Leed
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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17
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Bowden G, Kano H, Caparosa E, Tonetti D, Niranjan A, Monaco EA, Flickinger J, Arai Y, Lunsford LD. Stereotactic radiosurgery for arteriovenous malformations of the postgeniculate visual pathway. J Neurosurg 2015; 122:433-40. [DOI: 10.3171/2014.10.jns1453] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
A visual field deficit resulting from the management of an arteriovenous malformation (AVM) significantly impacts a patient's quality of life. The present study was designed to investigate the clinical and radiological outcomes of stereotactic radiosurgery (SRS) performed for AVMs involving the postgeniculate visual pathway.
METHODS
In this retrospective single-institution analysis, the authors reviewed their experience with Gamma Knife surgery for postgeniculate visual pathway AVMs performed during the period between 1987 and 2009.
RESULTS
During the study interval, 171 patients underwent SRS for AVMs in this region. Forty-one patients (24%) had a visual deficit prior to SRS. The median target volume was 6.0 cm3 (range 0.4–22 cm3), and 19 Gy (range 14–25 Gy) was the median margin dose. Obliteration of the AVM was confirmed in 80 patients after a single SRS procedure at a median follow-up of 74 months (range 5–297 months). The actuarial rate of total obliteration was 67% at 4 years. Arteriovenous malformations with a volume < 5 cm3 had obliteration rates of 60% at 3 years and 79% at 4 years. The delivered margin dose proved significant given that 82% of patients receiving ≥ 22 Gy had complete obliteration. The AVM was completely obliterated in an additional 18 patients after they underwent repeat SRS. At a median of 25 months (range 11–107 months) after SRS, 9 patients developed new or worsened visual field deficits. One patient developed a complete homonymous hemianopia, and 8 patients developed quadrantanopias. The actuarial risk of sustaining a new visual deficit was 3% at 3 years, 5% at 5 years, and 8% at 10 years. Fifteen patients had hemorrhage during the latency period, resulting in death in 9 of the patients. The annual hemorrhage rate during the latency interval was 2%, and no hemorrhages occurred after confirmed obliteration.
CONCLUSIONS
Despite an overall treatment mortality of 5%, related to latency interval hemorrhage, SRS was associated with only a 5.6% risk of new visual deficit and a final obliteration rate close to 80% in patients with AVMs of the postgeniculate visual pathway.
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Affiliation(s)
- Greg Bowden
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery
- 5University of Western Ontario, London, Ontario, Canada
| | - Hideyuki Kano
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery
| | - Ellen Caparosa
- 4University of Pittsburgh School of Medicine, University of Pittsburgh, Pennsylvania; and
| | - Daniel Tonetti
- 4University of Pittsburgh School of Medicine, University of Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery
| | - Edward A. Monaco
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery
| | | | - Yoshio Arai
- 2Radiation Oncology,
- 3Center for Image-Guided Neurosurgery
| | - L. Dade Lunsford
- Departments of 1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery
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18
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Watanabe T, Nagamine H, Ishiuchi S. Progression of cerebellar chronic encapsulated expanding hematoma during late pregnancy after gamma knife radiosurgery for arteriovenous malformation. Surg Neurol Int 2015; 5:S575-9. [PMID: 25593781 PMCID: PMC4287896 DOI: 10.4103/2152-7806.148054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/04/2014] [Indexed: 12/02/2022] Open
Abstract
Background: The etiology and appropriate management strategy of chronic encapsulated expanding hematoma during pregnancy after gamma knife radiosurgery for arteriovenous malformation (AVM) remain unclear. Case Description: A 34-year-old female developed chronic encapsulated expanding hematoma during late pregnancy, after angiographic disappearance of cerebellar AVM following two courses of gamma knife radiosurgery. The present case implicates pregnancy as a potential promoter of growth and enlargement of chronic encapsulated expanding hematoma, which may become life-threatening and require surgical intervention. Conclusion: Immediate surgical management after delivery may be associated with a favorable outcome, so close follow-up management and patient education are very important in women planning pregnancy.
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Affiliation(s)
- Takashi Watanabe
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hideki Nagamine
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
| | - Shogo Ishiuchi
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
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19
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Bowden G, Kano H, Yang HC, Niranjan A, Flickinger J, Lunsford LD. Gamma Knife surgery for arteriovenous malformations within or adjacent to the ventricles. J Neurosurg 2014; 121:1416-23. [DOI: 10.3171/2014.4.jns131943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The outcomes of stereotactic radiosurgery for arteriovenous malformations (AVMs) within or adjacent to the ventricular system are largely unknown. This study assessed the long-term outcomes and hemorrhage risks for patients with AVMs within this region who underwent Gamma Knife surgery (GKS) at the University of Pittsburgh.
Methods
The authors retrospectively identified 188 patients with ventricular-region AVMs who underwent a single-stage GKS procedure during a 22-year interval. The median patient age was 32 years (range 3–80 years), the median target volume was 4.6 cm3 (range 0.1–22 cm3), and the median marginal dose was 20 Gy (range 13–27 Gy).
Results
Arteriovenous malformation obliteration was confirmed by MRI or angiography in 89 patients during a median follow-up of 65 months (range 2–265 months). The actuarial rates of total obliteration were 32% at 3 years, 55% at 4 years, 60% at 5 years, and 64% at 10 years. Higher rates of AVM obliteration were obtained in the 26 patients with intraventricular AVMs. Twenty-five patients (13%) sustained a hemorrhage during the initial latency interval after GKS, indicating an annual hemorrhage rate of 3.4% prior to AVM obliteration. No patient experienced a hemorrhage after AVM obliteration was confirmed by imaging. Permanent neurological deficits due to adverse radiation effects developed in 7 patients (4%).
Conclusions
Although patients in this study demonstrated an elevated hemorrhage risk that remained until complete obliteration, GKS still proved to be a generally safe and effective treatment for patients with these high-risk intraventricular and periventriclar AVMs.
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Affiliation(s)
- Greg Bowden
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
- 4University of Western Ontario, London, Ontario, Canada; and
| | - Hideyuki Kano
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Huai-che Yang
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
- 5Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Ajay Niranjan
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
| | - John Flickinger
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania
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20
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Bowden G, Kano H, Tonetti D, Niranjan A, Flickinger J, Lunsford LD. Stereotactic radiosurgery for arteriovenous malformations of the cerebellum. J Neurosurg 2014; 120:583-90. [DOI: 10.3171/2013.9.jns131022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Arteriovenous malformations (AVMs) of the posterior fossa have an aggressive natural history and propensity for hemorrhage. Although the cerebellum accounts for the majority of the posterior fossa volume, there is a paucity of stereotactic radiosurgery (SRS) outcome data for AVMs of this region. The authors sought to evaluate the long-term outcomes and risks of cerebellar AVM radiosurgery.
Methods
This single-institution retrospective analysis reviewed the authors' experience with Gamma Knife surgery during the period 1987–2007. During this time 64 patients (median age 47 years, range 8–75 years) underwent SRS for a cerebellar AVM. Forty-seven patients (73%) presented with an intracranial hemorrhage. The median target volume was 3.85 cm3 (range 0.2–12.5 cm3), and the median marginal dose was 21 Gy (range 15–25 Gy).
Results
Arteriovenous malformation obliteration was confirmed by MRI or angiography in 40 patients at a median follow-up of 73 months (range 4–255 months). The actuarial rates of total obliteration were 53% at 3 years, 69% at 4 years, and 76% at 5 and 10 years. Elevated obliteration rates were statistically higher in patients who underwent AVM SRS without prior embolization (p = 0.005). A smaller AVM volume was also associated with a higher rate of obliteration (p = 0.03). Four patients (6%) sustained a hemorrhage during the latency period and 3 died. The cumulative rates of AVM hemorrhage after SRS were 6% at 1, 5, and 10 years. This correlated with an overall annual hemorrhage rate of 2.0% during the latency interval. One patient experienced a hemorrhage 9 years after confirmed MRI and angiographic obliteration. A permanent neurological deficit due to adverse radiation effects developed in 1 patient (1.6%) and temporary complications were seen in 2 additional patients (3.1%).
Conclusions
Stereotactic radiosurgery proved to be most effective for patients with smaller and previously nonembolized cerebellar malformations. Hemorrhage during the latency period occurred at a rate of 2.0% per year until obliteration occurred.
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Affiliation(s)
- Greg Bowden
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
- 5Departnemt of Neurological Surgery, University of Western Ontario, London, Ontario, Canada
| | - Hideyuki Kano
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
| | - Daniel Tonetti
- 4University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
| | - John Flickinger
- 2Radiation Oncology and
- 3the Center for Image-Guided Neurosurgery,
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
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21
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22
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Sheehan J. Stereotactic radiosurgery for functioning pituitary adenomas--a higher dose is better but only up to a point. World Neurosurg 2013; 82:e75-6. [PMID: 23459276 DOI: 10.1016/j.wneu.2013.02.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 02/22/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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23
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Yen CP, Matsumoto JA, Wintermark M, Schwyzer L, Evans AJ, Jensen ME, Shaffrey ME, Sheehan JP. Radiation-induced imaging changes following Gamma Knife surgery for cerebral arteriovenous malformations. J Neurosurg 2013; 118:63-73. [PMID: 23140155 DOI: 10.3171/2012.10.jns12402] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to evaluate the incidence, severity, clinical manifestations, and risk factors of radiation-induced imaging changes (RIICs) following Gamma Knife surgery (GKS) for cerebral arteriovenous malformations (AVMs).
Methods
A total of 1426 GKS procedures performed for AVMs with imaging follow-up available were analyzed. Radiation-induced imaging changes were defined as newly developed increased T2 signal surrounding the treated AVM nidi. A grading system was developed to categorize the severity of RIICs. Grade I RIICs were mild imaging changes imposing no mass effect on the surrounding brain. Grade II RIICs were moderate changes causing effacement of the sulci or compression of the ventricles. Grade III RIICs were severe changes causing midline shift of the brain. Univariate and multivariate logistic regression analyses were applied to test factors potentially affecting the occurrence, severity, and associated symptoms of RIICs.
Results
A total of 482 nidi (33.8%) developed RIICs following GKS, with 281 classified as Grade I, 164 as Grade II, and 37 as Grade III. The median duration from GKS to the development of RIICs was 13 months (range 2–124 months). The imaging changes disappeared completely within 2–128 months (median 22 months) following the development of RIICs. The RIICs were symptomatic in 122 patients, yielding an overall incidence of symptomatic RIICs of 8.6%. Twenty-six patients (1.8%) with RIICs had permanent deficits. A negative history of prior surgery, no prior hemorrhage, large nidus, and a single draining vein were associated with a higher risk of RIICs.
Conclusions
Radiation-induced imaging changes are the most common adverse effects following GKS. Fortunately, few of the RIICs are symptomatic and most of the symptoms are reversible. Patients with a relatively healthy brain and nidi that are large, or with a single draining vein, are more likely to develop RIICs.
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Affiliation(s)
| | - Julie A. Matsumoto
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Max Wintermark
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | | | - Avery J. Evans
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Mary E. Jensen
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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Williams BJ, Park DM, Sheehan JP. Bevacizumab used for the treatment of severe, refractory perilesional edema due to an arteriovenous malformation treated with stereotactic radiosurgery. J Neurosurg 2012; 116:972-7. [PMID: 22324417 DOI: 10.3171/2012.1.jns111627] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a case of an arteriovenous malformation of the central sulcus treated with Gamma Knife surgery. The patient developed perilesional edema 9 months after treatment and experienced severe headache and hemiparesis. Her symptoms were refractory to corticosteroid therapy and pain management. She was subsequently treated with bevacizumab with striking improvement in her symptoms and results of neuroimaging studies. This is the first time that bevacizumab has been used to control severe refractory perilesional edema related to an intracranial arteriovenous malformation.
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Kano H, Kondziolka D, Flickinger JC, Yang HC, Flannery TJ, Awan NR, Niranjan A, Novotny J, Lunsford LD. Stereotactic radiosurgery for arteriovenous malformations, Part 3: outcome predictors and risks after repeat radiosurgery. J Neurosurg 2012; 116:21-32. [DOI: 10.3171/2011.9.jns101741] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to evaluate the outcomes and risks of repeat stereotactic radiosurgery (SRS) for incompletely obliterated cerebral arteriovenous malformations (AVMs).
Methods
Between 1987 and 2006, Gamma Knife surgery was performed in 996 patients with AVMs. During this period, repeat SRS was performed in 105 patients who had incompletely obliterated AVMs at a median of 40.9 months after initial SRS (range 27.5–139 months). The median AVM target volume was 6.4 cm3 (range 0.2–26.3 cm3) at initial SRS but was reduced to 2.3 cm3 (range 0.1–18.2 cm3) at the time of the second procedure. The median margin dose at both initial SRS and repeat SRS was 18 Gy.
Results
The actuarial rate of total obliteration by angiography or MR imaging after repeat SRS was 35%, 68%, 77%, and 80% at 3, 4, 5, and 10 years, respectively. The median time to complete angiographic or MR imaging obliteration after repeat SRS was 39 months. Factors associated with a higher rate of AVM obliteration were smaller residual AVM target volume (p = 0.038) and a volume reduction of 50% or more after the initial procedure (p = 0.014). Seven patients (7%) had a hemorrhage in the interval between initial SRS and repeat SRS. Seventeen patients (16%) had hemorrhage after repeat SRS and 6 patients died. The cumulative actuarial rates of new AVM hemorrhage after repeat SRS were 1.9%, 8.1%, 10.1%, 10.1%, and 22.4% at 1, 2, 3, 5, and 10 years, respectively, which translate to annual hemorrhage rates of 4.05% and 1.79% of patients developing new post–repeat-SRS hemorrhages per year for Years 0–2 and 2–10 following repeat SRS. Factors associated with a higher risk of hemorrhage after repeat SRS were a greater number of prior hemorrhages (p = 0.008), larger AVM target volume at initial SRS (p = 0.010), larger target volume at repeat SRS (p = 0.002), initial AVM volume reduction less than 50% (p = 0.019), and a higher Pollock-Flickinger score (p = 0.010). Symptomatic adverse radiation effects developed in 5 patients (4.8%) after initial SRS and in 10 patients (9.5%) after repeat SRS. Prior embolization (p = 0.022) and a higher Spetzler-Martin grade (p = 0.004) were significantly associated with higher rates of adverse radiation effects after repeat SRS. Delayed cyst formation occurred in 5 patients (4.8%) at a median of 108 months after repeat SRS (range 47–184 months).
Conclusions
Repeat SRS for incompletely obliterated AVMs increases the eventual obliteration rate. Hemorrhage after obliteration did not occur in this series. The best results for patients with incompletely obliterated AVMs were seen in patients with a smaller residual nidus volume and no prior hemorrhages.
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Affiliation(s)
- Hideyuki Kano
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Douglas Kondziolka
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - John C. Flickinger
- 1Departments of Neurological Surgery and
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Huai-che Yang
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
- 4Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Thomas J. Flannery
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Nasir R. Awan
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- 1Departments of Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Josef Novotny
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery and
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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Sheehan J. Radiosurgery. J Neurosurg 2011; 116:1-2; discussion 9-10. [PMID: 22077449 DOI: 10.3171/2011.6.jns11844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Yashar P, Amar AP, Giannotta SL, Yu C, Pagnini PG, Liu CY, Apuzzo MLJ. Cerebral arteriovenous malformations: issues of the interplay between stereotactic radiosurgery and endovascular surgical therapy. World Neurosurg 2011; 75:638-47. [PMID: 21704930 DOI: 10.1016/j.wneu.2011.01.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 01/25/2011] [Accepted: 01/28/2011] [Indexed: 11/25/2022]
Abstract
Intracranial arteriovenous malformations (AVMs) are congenital lesions frequently diagnosed as a result of hemorrhage or other neurological symptoms. Prevention of such devastating neurological injury has promoted a variety of treatment strategies. The rich history of multimodal therapy in the treatment of AVMs includes microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the biology and natural history of AVMs, as well as their treatment with both SRS and endovascular neurosurgery. It considers various paradigms and goals of endovascular treatment, along with relevant issues such as the features of an AVM to be targeted. Issues of the interplay between SRS and endovascular neurosurgery include the compartments of an embolized AVM to contain within the radiosurgery plan, the radioprotective and radiosensitizing effects of the embolic agent, the durability of embolization, and the sequencing of embolization with respect to the radiosurgical treatment. Published literature on these topics is sparse, and the flimsiness of the data offers limited guidance.
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Affiliation(s)
- Parham Yashar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Stahl JM, Chi YY, Friedman WA. Repeat Radiosurgery for Intracranial Arteriovenous Malformations. Neurosurgery 2011; 70:150-4; discussion 154. [PMID: 21743357 DOI: 10.1227/neu.0b013e31822c5740] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Despite a high success rate in the stereotactic radiosurgical treatment of intracranial arteriovenous malformations (AVMs) that cannot be safely resected with microsurgery, some patients must be managed after treatment failure.
OBJECTIVE
To provide an update on the use of repeat linear accelerator radiosurgery as a treatment for failed AVM radiosurgery at the University of Florida.
METHODS
We reviewed 103 patients who underwent repeat radiosurgical treatment for residual AVM at the University of Florida between December 1991 and December 2007. Each of these patients had at least 2 radiosurgical treatments for the same AVM. Patient information, including AVM nidus volume, prescription dose, age, and sex, was collected at the time of initial treatment and again at the time of retreatment. Patients were followed up after treatment with magnetic resonance, computed tomography, and angiographic imaging at standard intervals to determine the status of their AVM. The median follow-up after retreatment was 31 months.
RESULTS
Between the first and second treatments, the median AVM nidus volume was decreased by 69% (from a median volume of 12.7 to 4.0 cm3), allowing the median prescribed dose to be increased from 1500 cGy on initial treatment to 1750 cGy on retreatment. The final obliteration rate on retreatment was 65.3%. After salvage retreatment, 5 patients (4.9%) experienced radiation-induced complications, and 6 patients (5.8%) experienced posttreatment hemorrhage.
CONCLUSION
Repeat radiosurgery is a safe and effective salvage treatment for AVMs.
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Affiliation(s)
- John M. Stahl
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida
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