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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [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: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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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 Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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Mehta TI, Arun A, Heiberger C, Cognetti D, Ray TR, Amans MR, Fargen K, Huisman TAGM, Hui F. Venous Pathologies and Interventions of the Head. Semin Neurol 2023; 43:439-453. [PMID: 37562454 DOI: 10.1055/s-0043-1771512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.
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Affiliation(s)
- Tej Ishaan Mehta
- The United States Air Force Medical Corps, Falls Church, Virginia
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Anirudh Arun
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caleb Heiberger
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David Cognetti
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Ray
- Department of Mechanical Engineering, University of Hawai'i at Mānoa, Honolulu, Hawaii
- Department of Cellular and Molecular Biology, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii
| | - Matthew R Amans
- Department of Radiology, University of California San Francisco, San Francisco, California
- Department of Neurosurgery, University of California San Francisco, San Francisco, California
| | - Kyle Fargen
- Department of Neurosurgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Thierry A G M Huisman
- Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Ferdinand Hui
- Department of Radiology, The Queen's Medical Center, Honolulu, Hawaii
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Yahia-Cherif M, Fenton C, Bonnet T, De Witte O, Simon S, De Maertelaer V, Mine B, Lefranc F, Lubicz B. Embolization before Gamma Knife radiosurgery for cerebral arteriovenous malformations does not negatively impact its obliteration rate: a series of 190 patients. Neuroradiology 2023; 65:391-399. [PMID: 36271057 DOI: 10.1007/s00234-022-03066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/09/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs. METHODS The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses. RESULTS The mean AVM size was significantly reduced after embolization (p < 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%). CONCLUSIONS This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality.
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Affiliation(s)
- Mehdi Yahia-Cherif
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Chifra Fenton
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Stéphane Simon
- Department of Medical Physics, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Viviane De Maertelaer
- Department of Biostatistics, IRIBHM, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Kim MJ, Jung HH, Kim YB, Chang JH, Chang JW, Park KY, Chang WS. Comparison of Single-Session, Neoadjuvant, and Adjuvant Embolization Gamma Knife Radiosurgery for Arteriovenous Malformation. Neurosurgery 2022; 92:986-997. [PMID: 36700732 DOI: 10.1227/neu.0000000000002308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The purpose of intracranial arteriovenous malformations (AVMs) treatment is to prevent bleeding or subsequent hemorrhage with complete obliteration. For large, difficult-to-treat AVMs, multimodal approaches including surgery, endovascular embolization, and gamma knife radiosurgery (GKRS) are frequently used. OBJECTIVE To analyze the outcomes of AVMs treated with single-session, neoadjuvant, and adjuvant embolization GKRS. METHODS We retrospectively reviewed a database of 453 patients with AVMs who underwent GKRS between January 2007 and December 2017 at our facility. The obliteration rate, incidence of latent period bleeding, cyst formation, and radiation-induced changes were compared among the 3 groups, neoadjuvant-embolized, adjuvant-embolized, nonembolized group. In addition, the variables predicting AVM obliteration and complications were investigated. RESULTS A total of 228 patients were enrolled in this study. The neoadjuvant-embolized, adjuvant-embolized, and nonembolized groups comprised 29 (12.7%), 19 (8.3%), and 180 (78.9%) patients, respectively. Significant differences were detected among the 3 groups in the history of previous hemorrhage and the presence of aneurysms ( P < .0001). Multivariate Cox regression analyses revealed a significant inverse correlation between neoadjuvant embolization and obliteration occurring 36 months after GKRS (hazard ratio, 0.326; P = .006). CONCLUSION GKRS with either neoadjuvant or adjuvant embolization is a beneficial approach for the treatment of AVMs with highly complex angioarchitectures that are at risk for hemorrhage during the latency period. Embolization before GKRS may be a negative predictive factor for late-stage obliteration (>36 months). To confirm our conclusions, further studies involving a larger number of patients and continuous follow-up are necessary.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University College of Medicine, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Chang H, Silva MA, Weng J, Kovacevic J, Luther E, Starke RM. The impact of embolization on radiosurgery obliteration rates for brain arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:28. [PMID: 36576595 DOI: 10.1007/s10143-022-01935-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 11/25/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
There exists no consensus in the literature regarding the impact of pre-stereotactic radiosurgery (SRS) embolization on obliteration rates and clinical outcome after radiosurgery treatment of intracranial arteriovenous malformations (AVM). We performed a systematic review of four databases and included studies with at least 10 patients evaluating obliteration rates of intracranial AVMs treated with SRS alone (SRS cohort) and combined pre-SRS embolization followed by SRS (E + SRS cohort). Meta-analytic results were pooled together via random-effects models. A total of 43 studies, with 7103 patients, were included in our analysis. Among our included patients, complete obliteration was achieved in 51.5% (964/1871) of patients in the E + SRS cohort as compared to 61.5% (3217/5231) of patients in the SRS cohort. Meta-analysis of the pooled data revealed that obliteration was significantly lower in the E + SRS cohort (pooled OR = 0.64, 95% CI = 0.54-0.75, p < 0.0001). The use of pre-SRS embolization was significantly associated with lower AVM obliteration rates when compared to treatment with SRS alone. Our analysis seeks to provide a macroscopic insight into the complex interaction between pre-SRS embolization and brain AVM obliteration rates and prognosis. Pre-SRS embolization may still be beneficial in select patients, and further studies are needed to identify patients who benefit from neoadjuvant AVM embolization.
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Affiliation(s)
- Henry Chang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA.
| | - Michael A Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - John Weng
- Florida State University College of Medicine, Tallahassee, FL, USA
| | | | - Evan Luther
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
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Mendez C, Gete E. Volume staging for arteriovenous malformation SRS treatment using VMAT. J Appl Clin Med Phys 2022; 23:e13815. [PMID: 36354977 PMCID: PMC9797165 DOI: 10.1002/acm2.13815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/25/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
Volume staging involves dividing the target volume into smaller parts and treating each part separately. In this study, the feasibility of volume-staged stereotactic radiosurgery (VS-SRS) on a linear accelerator using volumetric modulated arc therapy (VMAT) and a frameless patient positioning system is investigated. Ten patients, previously treated with hypofractionated stereotactic radiotherapy with arteriovenous malformation (AVM) sized from 1.6 to 4.0 cm in diameter, were selected. VS-SRS plans were created with the VMAT technique on the Varian Eclipse treatment planning system (TPS) using the TrueBeam STx linear accelerator. For each patient, an AVM-VMAT set was planned with the AVM as the target and a PTV-VMAT set using the (PTV = AVM+1 mm) as the target. All targets were divided into two sub-volumes. The TPS data from the AVM-VMAT plans was compared to Gamma Knife (GK) VS-SRS plan data available in the literature. The AVM-VMAT and PTV-VMAT plans were compared to investigate the effect of a 1 mm PTV margin on normal brain (NB) dose. End-to-end testing was performed using a GaFchromic EBT3 film and point-dose measurements. Dosimetric effects of multiple setups were investigated through film-to-film comparisons. Median target dose coverage, NB V12Gy , and conformity index for the AVM-VMAT plans were 97.5%, 17 cm3 , and 0.8, respectively. PTV-VMAT plans attained comparable target dose coverage, but the average NB V12Gy increased by 48.9% when compared to the AVM-VMAT plans. Agreement of point-dose measurements with TPS calculations was -0.6% when averaged over all patients. Gamma analysis passing rates were above 90% for all film-to-film comparisons (2%/1 mm criteria), and for the film to TPS comparison (5%/1 mm). This work suggests that VMAT is capable of producing VS-SRS plans with similar dose falloff characteristics as GK plans. NB dose depends on PTV margin size, and two-stage treatment setups do not appear to contribute additional uncertainty to treatment delivery.
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Affiliation(s)
- Claudia Mendez
- Department of Physics and AstronomyUniversity of British ColumbiaVancouverBritish ColumbiaCanada,BC Cancer, Abbotsford CenterAbbotsfordBritish ColumbiaCanada
| | - Ermias Gete
- BC Cancer, Vancouver CenterVancouverBritish ColumbiaCanada
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Hasegawa T, Kato T, Naito T, Mizuno A, Koketsu Y, Hirayama K, Niwa H. Effect of embolization before stereotactic radiosurgery for brain arteriovenous malformations: a case-control study with propensity score matching. J Neurosurg 2022; 138:955-961. [PMID: 36087321 DOI: 10.3171/2022.7.jns221343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate whether endovascular embolization prior to stereotactic radiosurgery (SRS) has a negative impact on nidus obliteration for patients with arteriovenous malformations (AVMs). METHODS A total of 704 eligible patients with AVM who did not undergo prior surgery or radiotherapy were evaluated. Of these patients, 593 were treated with SRS only, and 111 were treated with embolization followed by SRS (E+SRS). Most patients in the E+SRS group (88%) underwent embolization with n-butyl-2-cyanoacrylate. In the comparison of radiosurgical outcomes between patients treated with SRS only and E+SRS, these groups were matched in a 1:1 ratio using propensity score matching to eliminate differences in basic characteristics. The primary outcome was to compare the nidus obliteration rates between the SRS-only and E+SRS groups. The secondary outcomes were the comparison of cumulative hemorrhage rates and the incidence of cyst formation or chronic encapsulated hematoma after SRS between these groups. RESULTS In the unmatched cohorts, the actuarial 3-, 5-, and 8-year nidus obliteration rates after a single SRS session were 49.6%, 69.4%, and 74.1% in the SRS-only group, respectively, and 30.7%, 50.9%, and 68.6% in the E+SRS group, respectively (p = 0.001). In the matched cohort of 98 patients in each group, the rates were 47.1%, 62.0%, and 69.6% in the SRS-only group and 32.5%, 55.3%, and 75.0% in the E+SRS group, respectively (p = 0.24). There was no significant difference in either cumulative hemorrhage or the incidence of cyst formation or chronic encapsulated hematoma between the groups. CONCLUSIONS Pre-SRS embolization did not affect nidus obliteration rates, cumulative hemorrhage rates, or the incidence of cyst formation or chronic encapsulated hematoma as late adverse radiation effects in patients with AVM treated with SRS.
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Ilyas A, Chen CJ, Abecassis IJ, Al-Saiegh F, Ironside N, Jabbour PM, Tjoumakaris S, Gooch MR, Lee CC, Sheehan JP, Ding D. Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis. Neurosurgery 2022; 91:684-692. [PMID: 36001787 DOI: 10.1227/neu.0000000000002115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs. OBJECTIVE To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies. METHODS We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage. RESULTS The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration. CONCLUSION SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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Li N, Yan D, Li Z, Chen Y, Ma L, Li R, Han H, Meng X, Jin H, Zhao Y, Chen X, Wang H, Zhao Y. Long-term outcomes of Spetzler-Martin grade IV and V arteriovenous malformations: a single-center experience. Neurosurg Focus 2022; 53:E12. [PMID: 35901717 DOI: 10.3171/2022.4.focus21648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to explore whether intervention can benefit Spetzler-Martin (SM) grade IV-V arteriovenous malformations (AVMs). METHODS Eighty-two patients with SM grade IV-V AVMs were retrospectively reviewed from 2015 to 2018. Patients were divided into two groups: those who received conservative management (22 cases [26.8%]) and intervention (60 cases [73.2%], including 21 cases of microsurgery, 19 embolization, and 20 hybrid surgery). Neurofunctional outcomes were assessed with the modified Rankin Scale (mRS). The primary outcome was long-term neurofunctional status, and the secondary outcomes were short-term neurofunctional status, long-term obliteration rate, seizure control, and risk of subsequent hemorrhage. RESULTS Regarding the primary outcome, after an average of 4.7 years of clinical follow-up, long-term neurofunctional outcomes were similar after conservative management or intervention (absolute difference -0.4 [95% CI -1.5 to 0.7], OR 0.709 [95% CI 0.461-1.090], p = 0.106), whereas intervention had an advantage over conservative management for avoidance of severe disability (defined as mRS score > 3) (1.7% vs 18.2%, absolute difference 16.5% [95% CI -23.6% to 56.6%], OR 0.076 [95% CI 0.008-0.727], p = 0.025). Regarding the secondary outcomes, intervention was conducive to better seizure control (Engel class I-II) (70.0% vs 0.0%, absolute difference 70.0% [95% CI 8.6%-131.4%], p = 0.010) and avoidance of subsequent hemorrhage (1.4% vs 6.0%, absolute difference 4.6% [95% CI -0.4% to 9.6%], p = 0.030). In the subgroup analysis based on different intervention modalities, microsurgery and hybrid surgery achieved higher complete obliteration rates than embolization (p < 0.001), and hybrid surgery resulted in significantly less intraoperative blood loss than microsurgery (p = 0.041). CONCLUSIONS Intervention is reasonable for properly indicated SM grade IV-V AVMs because it provides satisfactory seizure control with decreased risks of severe disability and subsequent hemorrhage than conservative management. Clinical trial registration no.: NCT04572568 (ClinicalTrials.gov).
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Affiliation(s)
- Nan Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Debin Yan
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Zhipeng Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Yu Chen
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Li Ma
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Ruinan Li
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Heze Han
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Xiangyu Meng
- 2Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Hengwei Jin
- 2Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Yang Zhao
- 3Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing
| | - Xiaolin Chen
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Hao Wang
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing.,4China National Clinical Research Center for Neurological Diseases, Beijing; and.,5Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Yuanli Zhao
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing.,3Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing.,4China National Clinical Research Center for Neurological Diseases, Beijing; and.,5Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
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10
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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11
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Abstract
The treatment of arteriovenous malformations (AVMs) has evolved over the last 10 years. It is now possible to see that obliteration continues for up to 10 years and that the final obliteration rate may be between 85% and 90%. Improved imaging has made the treatment more efficient and has reduced the complications. It is possible to treat larger AVMs in a single session than was previously thought possible without increases in the complication rates. In addition, treatments of larger lesions can be staged. The use of 3D rotating angiography produces remarkable images which can be imported into GammaPlan. On the other hand efforts are ongoing to avoid the need for digital subtraction angiography, which would make the treatment a lot more comfortable.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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12
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Burke RM, Chen CJ, Ding D, Buell TJ, Sokolowski J, Sheehan KA, Lee CC, Sheehan DE, Kano H, Kearns KN, Tzeng SW, Yang HC, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Effect of Prior Embolization on Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: An International Multicenter Study. Neurosurgery 2021; 89:672-679. [PMID: 34333653 DOI: 10.1093/neuros/nyab245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric brain arteriovenous malformations (AVMs) are a significant cause of morbidity but the role of multimodal therapy in the treatment of these lesions is not well understood. OBJECTIVE To compare the outcomes of stereotactic radiosurgery (SRS) with and without prior embolization for pediatric AVMs. METHODS We retrospectively evaluated the International Radiosurgery Research Foundation pediatric AVM database. AVMs were categorized, based on use of pre-embolization (E + SRS) or lack thereof (SRS-only). Outcomes were compared in unadjusted and inverse probability weight (IPW)-adjusted models. Favorable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). RESULTS The E + SRS and SRS-only cohorts comprised 91 and 448 patients, respectively. In unadjusted models, the SRS-only cohort had higher rates of obliteration (68.5% vs 43.3%, < .001) and favorable outcome (61.2% vs 36.3%, P < .001) but a lower rate of symptomatic RIC (9.0% vs 16.7%, P = .031). The IPW-adjusted rates of every outcome were similar between the 2 cohorts. However, cumulative obliteration rates at 3, 5, 8, and 10 yr remained higher in the absence of prior embolization (46.3%, 64.6%, 72.6%, and 77.4% for SRS-only vs 24.4%, 37.2%, 44.1%, and 48.7% for E + SRS cohorts, respectively; SHR = 0.449 [0.238-0.846], P = .013). CONCLUSION Embolization appears to decrease cumulative obliteration rates after SRS for pediatric AVMs without affecting the risk of post-treatment hemorrhage or adverse radiation effects arguing against the routine use of pre-SRS embolization. While endovascular therapy can be considered for occlusion of high-risk angioarchitectural features prior to SRS, future studies are necessary to clarify its role.
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Affiliation(s)
- Rebecca M Burke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jennifer Sokolowski
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kimball A Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Darrah E Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shih-Wei Tzeng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Paul P Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Florida, USA
| | - L 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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13
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Faramand A, Alan N, Kano H, Niranjan A, Agarwal N, Ozpinar A, Flickinger J, Lunsford LD. Does Variceal Drainage Affect Arteriovenous Malformation Obliteration and Hemorrhage Rates After Stereotactic Radiosurgery? A Case-Matched Analysis. Neurosurgery 2021; 89:680-685. [PMID: 34293174 DOI: 10.1093/neuros/nyab256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/08/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is widely accepted as a minimally invasive alternative to surgery in the management of arteriovenous malformations (AVMs). Dilated AVM outflow veins or varices may be caused by high-flow or partial outflow obstruction, which may increase the risk of a hemorrhage before or after SRS. OBJECTIVE To compare the obliteration and hemorrhage risks in patients with and without AVM varices (AVMv). METHODS From our prospective database of 1012 AVM patients who underwent Gamma Knife® (Elekta) SRS, we identified 103 patients with AVMv, and 847 patients without varices. The median follow-up was 52 mo. Balancing variable score matching was performed to compare obliteration and hemorrhage rates between the 2 groups. RESULTS Obliteration rates in the AVMv group were 38% at 3 yr, 65% at 4 yr, and 70% at 5 yr. Patients with an AVMv had no difference in the final obliteration rate compared to patients who did not have variceal drainage (P = .35). Actuarial hemorrhage after SRS in the matched patients with AVMv was 4.9%, 13%, and 13.7%, at 1, 3, and 5 yr, respectively. The rate of hemorrhage in the group with no varix was 2.9%, 5.4%, and 9.1% at 1, 3, and 5 yr, respectively (P = .14). CONCLUSION The presence of AVM variceal venous drainage did not affect the obliteration rate and did not confer a higher risk of a subsequent hemorrhage both before and after SRS.
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Affiliation(s)
- Andrew Faramand
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nima Alan
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hideuyki Kano
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajay Niranjan
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nitin Agarwal
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alp Ozpinar
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John Flickinger
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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14
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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15
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Preradiosurgery embolization in reducing the postoperative hemorrhage rate for patients with cerebral arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3197-3207. [PMID: 33864525 DOI: 10.1007/s10143-021-01530-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/10/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Few studies have examined the postoperative hemorrhage rate of cerebral arteriovenous malformations (AVMs) treated by embolization prior to stereotactic radiosurgery. The objective of this analysis was to compare the postoperative hemorrhage rate between AVMs treated with and those treated without preradiosurgery embolization. A systematic search of the PubMed and Embase databases was performed with no restriction on the publication period. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies with sufficient baseline and outcome data. The analysis was performed using Comprehensive Meta-Analysis (CMA) 2.0. Eleven studies comprising 2591 patients were eligible for analysis. There was no significant difference in the postoperative hemorrhage rate between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.140, 95% CI 0.851-1.526, p = 0.38). The obliteration rate was significantly lower in the E + SRS group than in the SRS group (OR 0.586, 95% CI 0.398-0.863, p = 0.007). No significant difference in permanent neurological deficits was identified between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.175, 95% CI 0.626-2.206, p = 0.616). Available data suggested that preradiosurgery embolization did not reduce the postoperative hemorrhage rate and resulted in a significantly lower obliteration rate than treatment with SRS alone.
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16
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Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6686167. [PMID: 33954197 PMCID: PMC8060080 DOI: 10.1155/2021/6686167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/01/2021] [Accepted: 04/01/2021] [Indexed: 12/03/2022]
Abstract
Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.
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17
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Meng X, He H, Liu P, Gao D, Chen Y, Sun S, Liu A, Li Y, Jin H. Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations. Front Neurol 2021; 12:647167. [PMID: 33859610 PMCID: PMC8042217 DOI: 10.3389/fneur.2021.647167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background and purpose: To evaluate whether a radiosurgery-based arteriovenous malformation (AVM) scale (RBAS) could be used to predict obliteration of brain arteriovenous malformations (bAVMs) supposed for combined endovascular embolization (EMB) and gamma knife surgery (GKS) treatment. Methods: bAVM patients who underwent GKS with or without previous EMB from January 2011 to December 2016 at our institution were retrospectively reviewed. The patients were categorized into a combined treatment group and a GKS group. A 1:1 propensity score matching (PSM) was used to match the two groups. Pre-EMB and pre-GKS RBAS were assessed for every patient. Multivariate analysis was performed to find factors associated with complete obliteration in the combined treatment group. Survival analysis based on sub-groups according to RBAS was performed to compare obliteration rate and find cutoffs for appropriate treatment modalities. Results: A total of 96 patients were involved, and each group comprised 48 patients. There was no difference between the two groups in terms of obliteration rate (75.0 vs. 83.3%, p = 0.174). Pre-EMB RBAS (p = 0.010) and the number of feeding arteries (p = 0.014) were independent factors associated with obliteration rate in the combined treatment group. For the combined treatment patients, sub-group analysis according to pre-EMB RBAS (score <1.0, 1.0-1.5, and >1.5) showed statistical difference in obliteration rate (p = 0.002). Sub-group analysis according to RBAS between the two groups showed that the obliteration rate of the GKS group is significantly higher than the combined group when RBAS >1.5 (47.4 vs. 66.7%, p = 0.036). Conclusions: The RBAS is proposed to be efficient in predicting obliteration of bAVMs supposed to receive combined EMB and GKS treatment. Patients with RBAS >1.5 are inclined to be more suitable for GKS instead of the combined treatment.
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Affiliation(s)
- Xiangyu Meng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hongwei He
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center, Beijing, China
| | - Hengwei Jin
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center, Beijing, China
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18
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Ruigrok YM. Management of Unruptured Cerebral Aneurysms and Arteriovenous Malformations. Continuum (Minneap Minn) 2020; 26:478-498. [PMID: 32224762 DOI: 10.1212/con.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Unruptured intracranial aneurysms and brain arteriovenous malformations (AVMs) may be detected as incidental findings on cranial imaging. This article provides a practical approach to the management of unruptured intracranial aneurysms and unruptured brain AVMs and reviews the risk of rupture, risk factors for rupture, preventive treatment options with their associated risks, and the approach of treatment versus observation for both types of vascular malformations. RECENT FINDINGS For unruptured intracranial aneurysms, scoring systems on the risk of rupture can help with choosing preventive treatment or observation with follow-up imaging. Although the literature provides detailed information on the complication risks of preventive treatment of unruptured intracranial aneurysms, individualized predictions of these procedural complication risks are not yet available. With observation with imaging, growth of unruptured intracranial aneurysms can be monitored, and prediction scores for growth can help determine the optimal timing of monitoring. The past years have revealed more about the risk of complications of the different treatment modalities for brain AVMs. A randomized clinical trial and prospective follow-up data have shown that preventive interventional therapy in patients with brain AVMs is associated with a higher rate of neurologic morbidity and mortality compared with observation. SUMMARY The risk of hemorrhage from both unruptured intracranial aneurysms and brain AVMs varies depending on the number of risk factors associated with hemorrhage. For both types of vascular malformations, different preventive treatment options are available, and all carry risks of complications. For unruptured intracranial aneurysms, the consideration of preventive treatment versus observation is complex, and several factors should be included in the decision making. Overall, it is recommended that patients with unruptured asymptomatic brain AVMs should be observed.
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Song J, Li P, Tian Y, An Q, Liu Y, Yang Z, Chen L, Quan K, Gu Y, Ni W, Zhu W, Mao Y. One-Stage Treatment in a Hybrid Operation Room to Cure Brain Arteriovenous Malformation: A Single-Center Experience. World Neurosurg 2020; 147:e85-e97. [PMID: 33348099 DOI: 10.1016/j.wneu.2020.11.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the principles and techniques of using a hybrid operation room in the treatment of brain arteriovenous malformation (BAVM). METHODS From October 1, 2016 to December 31, 2018, we treated 54 consecutive patients with nonemergent BAVM in a hybrid operation room. The clinical data, radiologic images, and outcomes were collected to establish a prospective database for evaluation. RESULTS Thirty-two male and 22 female patients were enrolled with a mean age of 32.6 ± 13.1 years (range, 10-61 years). Bleeding (n = 32, 59.3%) was the main clinical presentation, followed by headache (n = 27, 50.0%), seizures (n = 14, 25.9%), neurofunctional deficits (n = 16, 29.6%), and no symptoms (n = 2, 3.7%). Thirty-one patients (57.4%) accepted resection without intraoperative embolization, 18 (33.3%) were treated with combined embolization and resection, and 5 (9.3%) were cured with intraoperative embolization and resection was cancelled. All patients achieved total BAVM obliteration confirmed with intraoperative angiography. There were no significant differences in outcomes between low-grade (Spetzler-Martin grades I, II, and modified grade III-) and high-grade (Spetzler-Martin grades ≥IV and modified grade III+) groups, except that the high-grade group had more blood loss (667.9 ± 647.5 vs. 284.3 ± 148.6 mL; P = 0.046) and longer postoperative hospitalization (17.1 ± 9.1 vs. 10.8 ± 5.4 days; P = 0.026). At discharge, 52 patients (96.3%) had favorable outcomes (Glasgow Outcome Scale score ≥4). Forty-three patients (79.6%) received 1 year follow-up after treatment; 97.7% (n = 42) of these had ongoing favorable outcomes. However, 4 patients with low-grade BAVM had recurrence. CONCLUSIONS The hybrid operation room can ensure safe, comprehensive treatment of BAVM, offering the opportunity for a favorable curative treatment in 1 stage.
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Affiliation(s)
- Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yingjun Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Zixiao Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
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20
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Burke RM, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee JYK, Sheehan JP. Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations. J Neurosurg 2020; 135:742-750. [PMID: 33307527 PMCID: PMC8192588 DOI: 10.3171/2020.7.jns201731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigations of the combined effects of neoadjuvant Onyx embolization and stereotactic radiosurgery (SRS) on brain arteriovenous malformations (AVMs) have not accounted for initial angioarchitectural features prior to neuroendovascular intervention. The aim of this retrospective, multicenter matched cohort study is to compare the outcomes of SRS with versus without upfront Onyx embolization for AVMs using de novo characteristics of the preembolized nidus. METHODS The International Radiosurgery Research Foundation AVM databases from 1987 to 2018 were retrospectively reviewed. Patients were categorized based on AVM treatment approach into Onyx embolization (OE) and SRS (OE+SRS) or SRS alone (SRS-only) cohorts and then propensity score matched in a 1:1 ratio. The primary outcome was AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiological and symptomatic radiation-induced changes (RICs), and cyst formation. Comparisons were analyzed using crude rates and cumulative probabilities adjusted for competing risk of death. RESULTS The matched OE+SRS and SRS-only cohorts each comprised 53 patients. Crude rates (37.7% vs 47.2% for the OE+SRS vs SRS-only cohorts, respectively; OR 0.679, p = 0.327) and cumulative probabilities at 3, 4, 5, and 6 years (33.7%, 44.1%, 57.5%, and 65.7% for the OE+SRS cohort vs 34.8%, 45.5%, 59.0%, and 67.1% for the SRS-only cohort, respectively; subhazard ratio 0.961, p = 0.896) of AVM obliteration were similar between the matched cohorts. The secondary outcomes of the matched cohorts were also similar. Asymptomatic and symptomatic embolization-related complication rates in the matched OE+SRS cohort were 18.9% and 9.4%, respectively. CONCLUSIONS Pre-SRS AVM embolization with Onyx does not appear to negatively influence outcomes after SRS. These analyses, based on de novo nidal characteristics, thereby refute previous studies that found detrimental effects of Onyx embolization on SRS-induced AVM obliteration. However, given the risks incurred by nidal embolization using Onyx, this neoadjuvant intervention should be used judiciously in multimodal treatment strategies involving SRS for appropriately selected large-volume or angioarchitecturally high-risk AVMs.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N. Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David E. Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Mehran B. Yusuf
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Shiao Y. Woo
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Rebecca M. Burke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David Mathieu
- Department of Neurosurgery, University of Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E. Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M. Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B. Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G. Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T. Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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21
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Kawashima M, Hasegawa H, Shin M, Shinya Y, Ishikawa O, Koizumi S, Katano A, Nakatomi H, Saito N. Outcomes of stereotactic radiosurgery for hemorrhagic arteriovenous malformations with or without prior resection or embolization. J Neurosurg 2020; 135:733-741. [PMID: 33276336 DOI: 10.3171/2020.7.jns201502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The major concern about ruptured arteriovenous malformations (rAVMs) is recurrent hemorrhage, which tends to preclude stereotactic radiosurgery (SRS) as a therapeutic modality for these brain malformations. In this study, the authors aimed to clarify the role of SRS for rAVM as a stand-alone modality and an adjunct for a remnant nidus after surgery or embolization. METHODS Data on 410 consecutive patients with rAVMs treated with SRS were analyzed. The patients were classified into groups, according to prior interventions: SRS-alone, surgery and SRS (Surg-SRS), and embolization and SRS (Embol-SRS) groups. The outcomes of the SRS-alone group were analyzed in comparison with those of the other two groups. RESULTS The obliteration rate was higher in the Surg-SRS group than in the SRS-alone group (5-year cumulative rate 97% vs 79%, p < 0.001), whereas no significant difference was observed between the Embol-SRS and SRS-alone groups. Prior resection (HR 1.78, 95% CI 1.30-2.43, p < 0.001), a maximum AVM diameter ≤ 20 mm (HR 1.81, 95% CI 1.43-2.30, p < 0.001), and a prescription dose ≥ 20 Gy (HR 2.04, 95% CI 1.28-3.27, p = 0.003) were associated with a better obliteration rate, as demonstrated by multivariate Cox proportional hazards analyses. In the SRS-alone group, the annual post-SRS hemorrhage rates were 1.5% within 5 years and 0.2% thereafter and the 10-year significant neurological event-free rate was 95%; no intergroup difference was observed in either outcome. The exclusive performance of SRS (SRS alone) was not a risk for post-SRS hemorrhage or for significant neurological events based on multivariate analyses. These results were also confirmed with propensity score-matched analyses. CONCLUSIONS The treatment strategy for rAVMs should be tailored with due consideration of multiple factors associated with the patients. Stand-alone SRS is effective for hemorrhagic AVMs, and the risk of post-SRS hemorrhage was low. SRS can also be favorably used for residual AVMs after initial interventions, especially after failed resection.
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Affiliation(s)
| | - Hirotaka Hasegawa
- Departments of1Neurosurgery and
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Atsuto Katano
- 3Radiology, University of Tokyo Hospital, Tokyo, Japan; and
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22
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Daou BJ, Palmateer G, Thompson BG, Maher CO, Hayman JA, Lam KL, Wahl DR, Kim M, Pandey AS. Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Evaluation of Obliteration and Review of Associated Predictors. J Stroke Cerebrovasc Dis 2020; 29:104863. [PMID: 32689634 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High arteriovenous malformation (AVM) obliteration rates have been reported with stereotactic radiosurgery (SRS), and multiple factors have been found to be associated with AVM obliteration. These predictors have been inconsistent throughout studies. We aimed to analyze our experience with linear accelerator (LINAC)-based SRS for brain AVMs, evaluate outcomes, assess factors associated with AVM obliteration and review the various reported predictors of AVM obliteration. METHODS Electronic medical records were retrospectively reviewed to identify consecutive patients with brain AVMs treated with SRS over a 27-year period with at least 2 years of follow-up. Logistic regression analysis was performed to identify factors associated with AVM obliteration. RESULTS One hundred twenty-eight patients with 142 brain AVMs treated with SRS were included. Mean age was 34.4 years. Fifty-two percent of AVMs were associated with a hemorrhage before SRS, and 14.8% were previously embolized. Mean clinical and angiographic follow-up times were 67.8 months and 58.6 months, respectively. The median Spetzler-Martin grade was 3. Mean maximal AVM diameter was 2.8 cm and mean AVM target volume was 7.4 cm3 with a median radiation dose of 16 Gy. Complete AVM obliteration was achieved in 80.3%. Radiation-related signs and symptoms were encountered in 32.4%, only 4.9% of which consisted of a permanent deficit. Post-SRS AVM-related hemorrhage occurred in 6.3% of cases. In multivariate analysis, factors associated with AVM obliteration included younger patient age (P = .019), male gender (P = .008), smaller AVM diameter (P = .04), smaller AVM target volume (P = .009), smaller isodose surface volume (P = .005), a higher delivered radiation dose (P = .013), and having only one major draining vein (P = .04). CONCLUSIONS AVM obliteration with LINAC-based radiosurgery was safe and effective and achieved complete AVM obliteration in about 80% of cases. The most prominent predictors of AVM success included AVM size, AVM volume, radiation dose, number of draining veins and patient age.
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Affiliation(s)
- Badih J Daou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Gregory Palmateer
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - B Gregory Thompson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Cormac O Maher
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - James A Hayman
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kwok L Lam
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Daniel R Wahl
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Michelle Kim
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Aditya S Pandey
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
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Byun J, Kwon DH, Lee DH, Park W, Park JC, Ahn JS. Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM. J Korean Neurosurg Soc 2020; 63:415-426. [PMID: 32423182 PMCID: PMC7365281 DOI: 10.3340/jkns.2020.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/29/2020] [Indexed: 11/27/2022] Open
Abstract
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.
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Affiliation(s)
- Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gamma Knife Radiosurgery Followed by Flow-Reductive Embolization for Ruptured Arteriovenous Malformation. J Clin Med 2020; 9:jcm9051318. [PMID: 32370235 PMCID: PMC7290943 DOI: 10.3390/jcm9051318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Aggressive treatment to achieve complete obliteration of brain arteriovenous malformation (AVM) is necessary in patients with a recent history of hemorrhage. The major drawback of Gamma knife radiosurgery (GKRS) alone for AVM is risk of bleeding during the latent period until the AVM occludes. At our center, patients who present with ruptured AVMs are frequently offered GKRS followed by embolization. The goal of this study was to compare outcomes of embolization for patients who have previously undergone GKRS for ruptured AVMs. Methods: A database including 150 GKRS for ruptured AVMs between November 2008 and October 2017 was reviewed. The embolized group was selected by including AVMs with post-GKRS embolization. The non-embolized group was defined as AVMs treated by GKRS alone. Outcomes including obliteration rate, incidence of repeat hemorrhage, and delayed cyst formation were compared between two groups. The predictive factors related to AVM obliteration and complications were analyzed. Results: The study consisted of 81 patients in the non-embolized group and 17 patients in the embolized group. Statistically significant differences were detected between the two groups with respect to age, Pollock-Flickinger score, Spetzler-Martin (SM) grade, eloquence of adjacent brain, and presence of aneurysms. The embolized group included more AVMs with larger median nidus volume. The predictive factors for the obliteration of ruptured AVMs were nidus volume, SM grade, Virginia Radiosurgery AVM Scale (VRAS), and Pollock-Flickinger score and for the subsequent hemorrhage were marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score. The obliteration rates and complication rates after GKRS between groups were not significantly different. However, this study demonstrated statistically significant difference in the cumulative incidence of obliteration in AVMs with SM grade III and IV (p = 0.037). Conclusion: Although the current study demonstrated similar results in patients who underwent GKRS with and without embolization, the embolized group included more AVMs with larger nidus volume, higher SM grade, Pollock-Flickinger score, and aneurysm, which have a lower chance of obliteration and a higher probability of repeat hemorrhage. GKRS followed by embolization appears to be a beneficial approach for the treatment of ruptured AVMs that are at risk for obliteration failure and repeat hemorrhage during the latency period after single-session GKRS alone. Further studies involving a larger number of cases and continuous follow-up are necessary to confirm our conclusions.
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Schmidhalter D, Henzen D, Herrmann E, Volken W, Mackeprang PH, Ermis E, Hemmatazad H, Honegger J, Haas B, Fix MK, Manser P. Evaluation of a new software prototype for frameless radiosurgery of arteriovenous malformations. Radiat Oncol 2019; 14:217. [PMID: 31791365 PMCID: PMC6889560 DOI: 10.1186/s13014-019-1422-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/20/2019] [Indexed: 11/12/2022] Open
Abstract
Background In order to locate an arteriovenous malformation, typically, a digital subtraction angiography (DSA) is carried out. To use the DSA for target definition an accurate image registration between CT and DSA is required. Carrying out a non-invasive, frameless procedure, registration of the 2D-DSA images with the CT is critical. A new software prototype is enabling this frameless procedure. The aim of this work was to evaluate the prototype in terms of targeting accuracy and reliability based on phantom measurements as well as with the aid of patient data. In addition, the user’s ability to recognize registration mismatches and quality was assessed. Methods Targeting accuracy was measured with a simple cubic, as well as with an anthropomorphic head phantom. Clearly defined academic targets within the phantoms were contoured on the CT. These reference structures were compared with the structures generated within the prototype. A similar approach was used with patient data, where the clinically contoured target served as the reference structure. An important error source decreasing the target accuracy comes from registration errors between CT and 2D-DSA. For that reason, the tools in BC provided to the user to check these registrations are very important. In order to check if the user is able to recognize registration errors, a set of different registration errors was introduced to the correctly registered CT and 2D-DSA image data sets of three different patients. Each of six different users rated the whole set of registrations within the prototype. Results The target accuracy of the prototype was found to be below 0.04 cm for the cubic phantom and below 0.05 cm for the anthropomorphic head phantom. The mean target accuracy for the 15 patient cases was found to be below 0.3 cm. In the registration verification part, almost all introduced registration errors above 1° or 0.1 cm were detected by the six users. Nevertheless, in order to quantify and categorize the possibility to detect mismatches in the registration process more data needs to be evaluated. Conclusion Our study shows, that the prototype is a useful tool that has the potential to fill the gap towards a frameless procedure when treating AVMs with the aid of 2D-DSA images in radiosurgery. The target accuracy of the prototype is similar to other systems already established in clinical routine.
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Affiliation(s)
- Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland.
| | - Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Evelyn Herrmann
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Werner Volken
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Paul-Henry Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Ekin Ermis
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Jonas Honegger
- Varian Medical Systems Imaging Laboratory GmbH, CH-5405, Dättwil, Switzerland
| | - Benjamin Haas
- Varian Medical Systems Imaging Laboratory GmbH, CH-5405, Dättwil, Switzerland
| | - Michael K Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
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26
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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Subat YW, Dasenbrock HH, Gross BA, Patel NJ, Frerichs KU, Du R, Aziz-Sultan MA. Periprocedural intracranial hemorrhage after embolization of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg 2019; 133:1417-1427. [PMID: 31518979 DOI: 10.3171/2019.5.jns183204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary goal of the treatment of cerebral arteriovenous malformations (AVMs) is angiographic occlusion to eliminate future hemorrhage risk. Although multimodal treatment is increasingly used for AVMs, periprocedural hemorrhage after transarterial embolization is a potential endovascular complication that is only partially understood and merits quantification. METHODS Searching the period between 1990 and 2019, the authors of this meta-analysis queried the PubMed and Embase databases for studies reporting periprocedural hemorrhage (within 30 days) after liquid embolization (using cyanoacrylate or ethylene vinyl alcohol copolymer) of AVMs. Random effects meta-analysis was used to evaluate the pooled rate of flow-related hemorrhage (those attributed to alterations in AVM dynamics), technical hemorrhage (those related to procedural complications), and total hemorrhage. Meta-regression was used to analyze the study-level predictors of hemorrhage, including patient age, Spetzler-Martin grade, hemorrhagic presentation, embolysate used, intent of treatment (adjuvant vs curative), associated aneurysms, endovascular angiographic obliteration, year of study publication, and years the procedures were performed. RESULTS A total of 98 studies with 8009 patients were included in this analysis, and the mean number of embolization sessions per patient was 1.9. The pooled flow-related and total periprocedural hemorrhage rates were 2.0% (95% CI 1.5%-2.4%) and 2.6% (95% CI 2.1%-3.0%) per procedure and 3.4% (95% CI 2.6%-4.2%) and 4.8% (95% CI 4.0%-5.6%) per patient, respectively. The mortality and morbidity rates associated with hemorrhage were 14.6% and 45.1%, respectively. Subgroup analyses revealed a pooled total hemorrhage rate per procedure of 1.8% (95% CI 1.0%-2.5%) for adjuvant (surgery or radiosurgery) and 4.6% (95% CI 2.8%-6.4%) for curative intent. The treatment of aneurysms (p = 0.04) and larger patient populations (p < 0.001) were significant predictors of a lower hemorrhage rate, whereas curative intent (p = 0.04), angiographic obliteration achieved endovascularly (p = 0.003), and a greater number of embolization sessions (p = 0.03) were significant predictors of a higher hemorrhage rate. There were no significant differences in periprocedural hemorrhage rates according to the years evaluated or the embolysate utilized. CONCLUSIONS In this study-level meta-analysis, periprocedural hemorrhage was seen after 2.6% of transarterial embolization procedures for cerebral AVMs. The adjuvant use of endovascular embolization, including in the treatment of associated aneurysms and in the presurgical or preradiosurgical setting, was a study-level predictor of significantly lower hemorrhage rates, whereas more aggressive embolization involving curative intent and endovascular angiographic obliteration was a predictor of a significantly higher total hemorrhage rate.
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Affiliation(s)
- Yosuf W Subat
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 4Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Hormuzdiyar H Dasenbrock
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 3Department of Neurosurgery, Rush University, Chicago, Illinois
| | - Bradley A Gross
- 5Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Nirav J Patel
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Kai U Frerichs
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - M Ali Aziz-Sultan
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
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Hung YC, Mohammed N, Eluvathingal Muttikkal TJ, Kearns KN, Li CE, Narayan A, Schlesinger D, Xu Z, Sheehan JP. The impact of preradiosurgery embolization on intracranial arteriovenous malformations: a matched cohort analysis based on de novo lesion volume. J Neurosurg 2019; 133:1156-1167. [PMID: 31470409 DOI: 10.3171/2019.5.jns19722] [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: 03/19/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The benefits and risks of pre-stereotactic radiosurgery (SRS) embolization have been reported in different studies. The goal of this study was to compare the long-term outcome of arteriovenous malformations (AVMs) treated with and without pre-SRS embolization. METHODS A database including 1159 patients with AVMs who underwent SRS was reviewed. The embolized group was selected by including AVMs with pre-SRS embolization, maximal diameter > 30 mm, and estimated volume > 8 ml. The nonembolized group was defined as AVMs treated by SRS alone with matched de novo nidus volume. Outcomes including incidences of favorable clinical outcome (obliteration without hemorrhage, cyst formation, worsening, or new seizures), obliteration, adverse effects, and angioarchitectural complexity were evaluated. RESULTS The study cohort comprised 17 patients in the embolized group (median AVM volume 17.0 ml) and 35 patients in the nonembolized group (median AVM volume 13.1 ml). The rates of obliteration (embolized cohort: 33%, 44%, and 56%; nonembolized cohort: 32%, 47%, and 47% at 4, 6, and 10 years, respectively) and favorable outcome were comparable between the 2 groups. However, the embolized group had a significantly higher incidence of repeat SRS (41% vs 23%, p = 0.012) and total procedures (median number of procedures 4 vs 1, p < 0.001), even with a significantly higher margin dose delivered at the first SRS (23 Gy vs 17 Gy, p < 0.001). The median angioarchitectural complexity score was reduced from 7 to 5 after embolization. Collateral flow and neovascularization were more frequently observed in the embolized nonobliterated AVMs. CONCLUSIONS Both embolization plus SRS and SRS alone were effective therapies for moderately large (8-39 ml) AVMs. Even with a significantly higher prescription dose at the time of initial SRS, the embolized group still required more procedures to reach final obliteration. The presence of collateral flow and neovascularization could be risk factors for a failure to obliterate following treatment.
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Affiliation(s)
- Yi-Chieh Hung
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
- 2Division of Neurosurgery, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
- 3Department of Recreation and Healthcare Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan; and
| | - Nasser Mohammed
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chelsea Eileen Li
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Aditya Narayan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - David Schlesinger
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Tam KY, Lim K, Zhu CXL, Chan KY, Poon WS, Poon D, Kam M, Cheung M, Wong KCG. Long-term outcomes of ruptured cerebral arteriovenous malformations in the paediatric population: A retrospective review in a regional hospital in Hong Kong. J Clin Neurosci 2019; 66:66-70. [DOI: 10.1016/j.jocn.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
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Baharvahdat H, Blanc R, Fahed R, Smajda S, Ciccio G, Desilles JP, Redjem H, Escalard S, Mazighi M, Chauvet D, Robert T, Sasannejad P, Piotin M. Endovascular Treatment for Low-Grade (Spetzler-Martin I-II) Brain Arteriovenous Malformations. AJNR Am J Neuroradiol 2019; 40:668-672. [PMID: 30792251 DOI: 10.3174/ajnr.a5988] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Surgical resection is usually considered as the first-line curative strategy for low-grade (Spetzler-Martin grade I-II) brain arteriovenous malformations because it has a high cure rate and low complications. The role of endovascular treatment remains to be clarified in this indication, especially after A Randomized Trial of Unruptured Brain Arteriovenous Malformations. Our objective was to assess the safety and efficacy of first-line endovascular treatment in low-grade brain arteriovenous malformation management at our institution. MATERIALS AND METHODS Patients with low-grade brain arteriovenous malformations treated primarily with embolization in our department between January 2005 and December 2015 were retrieved from our prospectively collected registry. The primary outcome was the brain arteriovenous malformation obliteration rate, and secondary outcomes were disability or death secondary to brain arteriovenous malformation embolization assessed through modification of the modified Rankin Scale. RESULTS Two hundred twenty-four patients completed endovascular treatment during the study period and represent our study population. Complete exclusion of brain arteriovenous malformations was achieved in 205 patients (92%), including 62.1% of brain arteriovenous malformation exclusions after a single endovascular treatment session. One patient died of a hemorrhagic complication after endovascular treatment, leading to a mortality rate of 0.4%. Twelve patients (5%) kept a permanent neurologic deficit secondary to a complication of the endovascular treatment. An overall good outcome (mRS 0-2) was reported in 179 patients (80%). CONCLUSIONS Endovascular treatment might be a suitable alternative to surgical resection for complete exclusion of selected low-grade brain arteriovenous malformations.
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Affiliation(s)
- H Baharvahdat
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - R Blanc
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - R Fahed
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - S Smajda
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - G Ciccio
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - J-P Desilles
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - H Redjem
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - S Escalard
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - M Mazighi
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - D Chauvet
- Neurosurgical Department (D.C.), Rothschild Foundation, Paris, France
| | - T Robert
- Neurosurgical Department (T.R.), Ente-Ospedaliero-Cantonale Ospedale Civico di Lugano, Lugano, Switzerland
| | - P Sasannejad
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - M Piotin
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
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Zhu D, Li Z, Zhang Y, Fang Y, Li Q, Zhao R, Hong B, Xu Y, Liu J, Huang Q. Gamma knife surgery with and without embolization for cerebral arteriovenous malformations: A systematic review and meta-analysis. J Clin Neurosci 2018; 56:67-73. [DOI: 10.1016/j.jocn.2018.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/06/2018] [Accepted: 07/08/2018] [Indexed: 11/27/2022]
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Ding D, Ilyas A, Sheehan JP. Contemporary Management of High-Grade Brain Arteriovenous Malformations. Neurosurgery 2018; 65:24-33. [DOI: 10.1093/neuros/nyy107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Kano H, Flickinger JC, Nakamura A, Jacobs RC, Tonetti DA, Lehocky C, Park KJ, Yang HC, Niranjan A, Lunsford LD. How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations. J Neurosurg 2018; 130:1809-1816. [PMID: 30028266 DOI: 10.3171/2018.2.jns172964] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 02/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The management of large-volume arteriovenous malformations (AVMs) with stereotactic radiosurgery (SRS) remains challenging. The authors retrospectively tested the hypothesis that AVM obliteration rates can be improved by increasing the percentage volume of an AVM that receives a minimal threshold dose of radiation. METHODS In 1992, the authors prospectively began to stage anatomical components in order to deliver higher single doses to AVMs > 15 cm3 in volume. Since that time 60 patients with large AVMs have undergone volume-staged SRS (VS-SRS). The median interval between the first stage and the second stage was 4.5 months (2.8-13.8 months). The median target volume was 11.6 cm3 (range 4.3-26 cm3) in the first-stage SRS and 10.6 cm3 (range 2.8-33.7 cm3) in the second-stage SRS. The median margin dose was 16 Gy (range 13-18 Gy) for both SRS stages. RESULTS AVM obliteration after the initial two staged volumetric SRS treatments was confirmed by MRI alone in 4 patients and by angiography in 11 patients at a median follow-up of 82 months (range 0.4-206 months) after VS-SRS. The post-VS-SRS obliteration rates on angiography were 4% at 3 years, 13% at 4 years, 23% at 5 years, and 27% at 10 years. In multivariate analysis, only ≥ 20-Gy volume coverage was significantly associated with higher total obliteration rates confirmed by angiography. When the margin dose is ≥ 17 Gy and the 20-Gy SRS volume included ≥ 63% of the total target volume, the angiographically confirmed obliteration rates increased to 61% at 5 years and 70% at 10 years. CONCLUSIONS The outcomes of prospective VS-SRS for large AVMs can be improved by prescribing an AVM margin dose of ≥ 17 Gy and adding additional isocenters so that ≥ 63% of the internal AVM dose receives more than 20 Gy.
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Affiliation(s)
- Hideyuki Kano
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John C Flickinger
- 2Radiation Oncology, and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Aya Nakamura
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel C Jacobs
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Craig Lehocky
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kyung-Jae Park
- 4Department of Neurosurgery, College of Medicine, Korea University, Seoul, South Korea; and
| | - Huai-Che Yang
- 5Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Ajay Niranjan
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Awake craniotomy for excision of arteriovenous malformations? A qualitative comparison study with stereotactic radiosurgery. J Clin Neurosci 2018. [DOI: 10.1016/j.jocn.2018.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Russell D, Peck T, Ding D, Chen CJ, Taylor DG, Starke RM, Lee CC, Sheehan JP. Stereotactic radiosurgery alone or combined with embolization for brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg 2018; 128:1338-1348. [DOI: 10.3171/2016.11.jns162382] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.
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Affiliation(s)
| | | | - Dale Ding
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Davis G. Taylor
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- 4Deparment of Neurological Surgery, University of Miami, Florida
| | - Cheng-Chia Lee
- 3Deparment of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Jason P. Sheehan
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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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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Ye Z, Ai X, You C. Letter to the Editor. Cyst formation after stereotactic radiosurgery for brain AVMs. J Neurosurg 2018; 129:259-262. [PMID: 29676692 DOI: 10.3171/2017.11.jns172776] [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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Patibandla MR, Ding D, Kano H, Starke RM, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Effect of treatment period on outcomes after stereotactic radiosurgery for brain arteriovenous malformations: an international multicenter study. J Neurosurg 2018; 130:579-588. [PMID: 29393755 DOI: 10.3171/2017.8.jns171336] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/01/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The role of and technique for stereotactic radiosurgery (SRS) in the management of arteriovenous malformations (AVMs) have evolved over the past four decades. The aim of this multicenter, retrospective cohort study was to compare the SRS outcomes of AVMs treated during different time periods. METHODS The authors selected patients with AVMs who underwent single-session SRS at 8 different centers from 1988 to 2014 with follow-up ≥ 6 months. The SRS eras were categorized as early (1988-2000) or modern (2001-2014). Statistical analyses were performed to compare the baseline characteristics and outcomes of the early versus modern SRS eras. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). RESULTS The study cohort comprised 2248 patients with AVMs, including 1584 in the early and 664 in the modern SRS eras. AVMs in the early SRS era were significantly smaller (p < 0.001 for maximum diameter and volume), and they were treated with a significantly higher radiosurgical margin dose (p < 0.001). The obliteration rate was significantly higher in the early SRS era (65% vs 51%, p < 0.001), and earlier SRS treatment period was an independent predictor of obliteration in the multivariate analysis (p < 0.001). The rates of post-SRS hemorrhage and radiological, symptomatic, and permanent RICs were not significantly different between the two groups. Favorable outcome was achieved in a significantly higher proportion of patients in the early SRS era (61% vs 45%, p < 0.001), but the earlier SRS era was not statistically significant in the multivariate analysis (p = 0.470) with favorable outcome. CONCLUSIONS Despite considerable advances in SRS technology, refinement of AVM selection, and contemporary multimodality AVM treatment, the study failed to observe substantial improvements in SRS favorable outcomes or obliteration for patients with AVMs over time. Differences in baseline AVM characteristics and SRS treatment parameters may partially account for the significantly lower obliteration rates in the modern SRS era. However, improvements in patient selection and dose planning are necessary to optimize the utility of SRS in the contemporary management of AVMs.
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Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Robert M Starke
- 3Department of Neurological Surgery, University of Miami, Florida
| | - John Y K Lee
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 5Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 6Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 7Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang P, Missios S, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Radiosurgery for Unruptured Brain Arteriovenous Malformations: An International Multicenter Retrospective Cohort Study. Neurosurgery 2018; 80:888-898. [PMID: 28431024 DOI: 10.1093/neuros/nyx181] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of intervention in the management of unruptured brain arteriovenous malformations (AVM) is controversial. OBJECTIVE To analyze in a multicenter, retrospective cohort study, the outcomes following radiosurgery for unruptured AVMs and determine predictive factors. METHODS We evaluated and pooled AVM radiosurgery data from 8 institutions participating in the International Gamma Knife Research Foundation. Patients with unruptured AVMs and ≥12 mo of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no postradiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes. RESULTS The unruptured AVM cohort comprised 938 patients with a median age of 35 yr. The median nidus volume was 2.4 cm 3 , 71% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 57%. The median radiosurgical margin dose was 21 Gy and follow-up was 71 mo. AVM obliteration was achieved in 65%. The annual postradiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 9% and 3%, respectively. Favorable outcome was achieved in 61%. In the multivariate logistic regression analysis, smaller AVM maximum diameter ( P = .001), the absence of AVM-associated arterial aneurysms ( P = .001), and higher margin dose ( P = .002) were found to be independent predictors of a favorable outcome. A margin dose ≥ 20 Gy yielded a significantly higher rate of favorable outcome (70% vs 36%; P < .001). CONCLUSION Radiosurgery affords an acceptable risk to benefit profile for patients harboring unruptured AVMs. These findings justify further prospective studies comparing radiosurgical intervention to conservative management for unruptured AVMs.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sher-brooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - Jason P Sheehan
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
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Pollock BE, Link MJ, Stafford SL, Lanzino G, Garces YI, Foote RL. Volume-Staged Stereotactic Radiosurgery for Intracranial Arteriovenous Malformations: Outcomes Based on an 18-Year Experience. Neurosurgery 2017; 80:543-550. [PMID: 28362923 DOI: 10.1093/neuros/nyw107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/27/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radiation-based treatment options of large intracranial arteriovenous malformations (AVM) must balance the likelihood of obliteration with the risk of adverse radiation effects (ARE). OBJECTIVE To analyze the efficacy and risks of volume-staged stereotactic radiosurgery (VS-SRS) for AVM. METHODS Retrospective study of 34 AVM patients having VS-SRS between 1997 and 2012. A median of 2 stages (range, 2-4) was used to treat a median AVM volume of 22.2 cm 3 (range, 7.4-56.7). The median AVM margin dose was 16 Gy (range, 14-18); the median radiosurgery-based AVM score was 2.81 (range, 1.54-6.45). The median follow-up after VS-SRS was 8.2 years (range, 3-13.3). RESULTS Nidus obliteration was noted in 18 patients (53%) after VS-SRS. The rate of obliteration was 14% at 3 years, 54% at 5 years, and 75% at 7 years. Six patients (18%) had 11 bleeds after VS-SRS. Two patients (6%) remained neurologically stable, 2 (6%) patients had significant deficits, and 2 patients (6%) died. The actuarial risk of a first bleed after VS-SRS was 6% at 1 year, 12% at 3 years, and 19% at 7 years. Six patients (18%) underwent repeat SRS; all achieved nidus obliteration for an overall cure rate of 71%. Two patients (6%) had a permanent ARE after VS-SRS or repeat SRS. CONCLUSION VS-SRS permitted large volume intracranial AVM to be treated with a low rate of ARE. Further study is needed on dose escalation and decreasing the treatment volume per stage to determine if this will increase the rate of obliteration with this technique.
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Affiliation(s)
- Bruce E Pollock
- Department of Neurological Surgery.,Department of Radiation Oncology
| | - Michael J Link
- Department of Neurological Surgery.,Department of Otorhinolaryngology
| | | | - Giuseppe Lanzino
- Department of Neurological Surgery.,Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Patibandla MR, Ding D, Kano H, Xu Z, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study. J Neurosurg 2017; 129:498-507. [PMID: 28885118 DOI: 10.3171/2017.3.jns162635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Due to the complexity of Spetzler-Martin (SM) Grade IV-V arteriovenous malformations (AVMs), the management of these lesions remains controversial. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after single-session stereotactic radiosurgery (SRS) for SM Grade IV-V AVMs and determine predictive factors. METHODS The authors retrospectively pooled data from 233 patients (mean age 33 years) with SM Grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at 8 participating centers in the International Gamma Knife Research Foundation. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cm3, 17.3 Gy, and 84.5 months, respectively. Statistical analyses were performed to identify factors associated with post-SRS outcomes. RESULTS At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37%, and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (p = 0.04) was found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM Grade IV-V AVMs compared with ruptured ones (p = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (p = 0.024) and radiologically evident RIC (p = 0.05) in the respective multivariate analyses. CONCLUSIONS In this multi-institutional study, single-session SRS had limited efficacy in the management of SM Grade IV-V AVMs. Favorable outcome was only achieved in a minority of unruptured SM Grade IV-V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume-staged SRS approach for large AVMs represents an alternative approach for high-grade AVMs, but it requires further investigation.
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Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh
| | - Zhiyuan Xu
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Y K Lee
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 4Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 5Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Impact of Onyx Embolization on Radiosurgical Management of Cerebral Arteriovenous Malformations: Treatment and Outcome. World Neurosurg 2017; 108:656-661. [PMID: 28890009 DOI: 10.1016/j.wneu.2017.08.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a well-established treatment modality for cerebral arteriovenous malformations (AVMs). The main limiting factor in the radiosurgical treatment of AVMs is the volume of the nidus, with high-grade lesions often requiring combined treatment to reduce the SRS target volume. To overcome this limitation, we have been using a combined treatment approach consisting of endovascular embolization with Onyx followed by SRS. OBJECTIVE To evaluate our clinical experience for safety and feasibility of this multimodality treatment approach. METHODS This is a retrospective review of all adult patients with cerebral AVMs who received SRS treatment to their AVM after endovascular embolization with Onyx between June 2007 and June 2014. RESULTS Thirty-five consecutive patients were identified. The mean follow-up period was 52.4 ± 22.6 months (range 18-97 months). We confirmed 18 (51.4%) complete nidus closures at a median time of 49.5 months (range 6.5-81 months) from SRS. High-resolution Magnetic resonance imaging/magnetic resonance angiography was performed routinely in all patients until closure of the nidus. Digital subtraction angiography was performed to confirm complete obliteration in 5 of the patients (28%); 13 patients are either planned for digital subtraction angiography or have refused it. In 6 patients (17%) a significant flow reduction was noted after a mean of 32 ± 16 months. No significant improvement was observed in 9 patients (26%) during the follow-up period. Two patients were lost to follow-up. CONCLUSIONS The multimodality treatment of cerebral AVMs using embolization with Onyx followed by SRS is feasible and safe. The use of Onyx significantly reduced the SRS treatment target volume.
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Miyachi S, Izumi T, Satow T, Srivatanakul K, Matsumoto Y, Terada T, Matsumaru Y, Kiyosue H. Effectiveness of Preradiosurgical Embolization with NBCA for Arteriovenous Malformations - Retrospective Outcome Analysis in a Japanese Registry of 73 Patients (J-REAL study). Neurointervention 2017; 12:100-109. [PMID: 28955512 PMCID: PMC5613041 DOI: 10.5469/neuroint.2017.12.2.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 08/02/2017] [Accepted: 08/10/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Recent reports have posed doubts about the effect of preradiosurgical embolization in brain arteriovenous malformation (AVM) because it makes the planning of stereotactic radiosurgery (SRS) difficult and has the risk of recanalization out of the target. We investigated whether the performance and quality of embolization may influence the success of SRS based on a retrospective case cohort study. Materials and Methods Seventy-three patients who underwent embolization followed by SRS between 2003 and 2012 in eight institutes with neurointerventionists were considered. They were divided into the following two groups at 3 years of follow up after the final SRS: “successful occlusion group” (S group), with radiologically complete occlusion of AVM; and “non-successful occlusion group” (N group) with persistent remnant nidus or abnormal vascular networks. Patient background, AVM profile, embolization performance grade and complications were compared in each group. The quality of embolization was evaluated with the new grading system: embolization performance grade (E grade), specializing the achievement of nidus embolization. E grade A was defined as sufficient nidus embolization with more than half of the total number of feeders achieving nidus penetration. E grade B was defined as less than half achievement of nidus embolization, and E grade C was defines as failure to perform nidus embolization. Results Forty-three patients were included in the S group, and 29 patients were included in the N group. The size and Spetzler-Martin grade of AVM and the rate of diffuse type was higher in the N group without statistical significance. The embolization performance level according to E grade indicated a significantly higher rate of successful embolization with more than 50% of nidus penetration in the S group (P<0.001). This difference was also confirmed in the subanalysis for limited cases, excluding smaller AVMs with complete occlusion with SRS alone (P=0.001). Conclusion The cause of the unsuccessful result of post-embolization SRS might be the large, diffuse angioarchitecture, but proper embolization with a high rate of nidus penetration to avoid recanalization is more important. Effective embolization is essential to contribute to and promote the effect of radiosurgery.
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Affiliation(s)
- Shigeru Miyachi
- Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Takashi Izumi
- Department of Neurosurgery and Endovascular Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Tomoaki Terada
- Department of Neurosurgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Hiro Kiyosue
- Department of Radiology, Oita University Hospital, Oita, Japan
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Peres CMA, Souza ECD, Teixeira MJ, Figueiredo EG, Caldas JGM. Impact of Associated Nidal Lesions in Outcome of Brain Arteriovenous Malformations After Radiosurgery with or without Embolization. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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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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46
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Zhang M, Connolly ID, Teo MK, Yang G, Dodd R, Marks M, Zuccarello M, Steinberg GK. Management of Arteriovenous Malformations Associated with Developmental Venous Anomalies: A Literature Review and Report of 2 Cases. World Neurosurg 2017; 106:563-569. [PMID: 28735125 DOI: 10.1016/j.wneu.2017.07.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Classification of cerebrovascular malformations has revealed intermediary lesions that warrant further review owing to their unusual presentation and management. We present 2 cases of arteriovenous malformation (AVM) associated with a developmental venous anomaly (DVA), and discuss the efficacy of previously published management strategies. METHODS Two cases of AVMs associated with DVA were identified, and a literature search for published cases between 1980 and 2016 was conducted. Patient demographic data and clinical features were documented. RESULTS In case 1, a 29-year-old female presenting with parenchymal hemorrhage and left homonymous hemianopia was found to have a right parieto-occipital AVM fed from the anterior cerebral, middle cerebral, and posterior cerebral arteries, with major venous drainage to the superior sagittal sinus. In case 2, imaging in a 34-year-old female evaluated for night tremors and incontinence revealed a left parietal AVM with venous drainage to the superior sagittal sinus. Including our 2 cases, 22 cases of coexisting AVMs and DVAs have been reported in the literature. At presentation, 68% had radiographic evidence of hemorrhage. Stereotactic radiosurgery was performed in 7 cases, embolization in 6 cases, surgical resection in 4 cases, and multimodal therapy in 5 cases. Radiography at follow-up demonstrated successful AVM obliteration in 67% of cases (12 of 18). CONCLUSIONS Patients with coexisting AVMs and DVAs tend to have a hemorrhagic presentation. Contrary to traditional AVM management, in these cases it is important to preserve the draining vein via the DVA to ensure a safe, sustained circulatory outflow of the associated brain parenchyma while achieving safe AVM obliteration.
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Affiliation(s)
- Michael Zhang
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA
| | - Ian D Connolly
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA
| | - Mario K Teo
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, UK
| | - George Yang
- Department of Neurosurgery, Mayfield Brain & Spine, Cincinnati, Ohio, USA
| | - Robert Dodd
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA
| | - Michael Marks
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA
| | - Mario Zuccarello
- Department of Neurosurgery, Mayfield Brain & Spine, Cincinnati, Ohio, USA
| | - Gary K Steinberg
- Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford, California, USA.
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Nerva JD, Barber J, Levitt MR, Rockhill JK, Hallam DK, Ghodke BV, Sekhar LN, Kim LJ. Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm. J Neurointerv Surg 2017; 10:258-267. [PMID: 28710086 DOI: 10.1136/neurintsurg-2017-013084] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial. OBJECTIVE To compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone. METHODS Seventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication. RESULTS Forty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively. CONCLUSION Pre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.
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Affiliation(s)
- John D Nerva
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA.,Department of Mechanical Engineering, University of Washington, Washington, USA
| | - Jason K Rockhill
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiation Oncology, University of Washington, Washington, USA
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
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Ilyas A, Chen CJ, Ding D, Mastorakos P, Taylor DG, Pomeraniec IJ, Lee CC, Sheehan J. Cyst formation after stereotactic radiosurgery for brain arteriovenous malformations: a systematic review. J Neurosurg 2017; 128:1354-1363. [PMID: 28548596 DOI: 10.3171/2016.12.jns162478] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs. METHODS A literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data. RESULTS Based on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years). CONCLUSIONS Cyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.
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Affiliation(s)
- Adeel Ilyas
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Dale Ding
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Panagiotis Mastorakos
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Davis G Taylor
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - I Jonathan Pomeraniec
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Cheng-Chia Lee
- 2Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Marks MP, Marcellus ML, Santarelli J, Dodd RL, Do HM, Chang SD, Adler JR, Mlynash M, Steinberg GK. Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2017; 99:471-476. [PMID: 28017742 DOI: 10.1016/j.wneu.2016.12.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/10/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Michael P Marks
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
| | - Mary L Marcellus
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Justin Santarelli
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Robert L Dodd
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Huy M Do
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA; Department of Neurology, Stanford University Medical Center, Stanford, California, USA
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50
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Bowden G, Cavaleri J, Kano H, Monaco E, Niranjan A, Flickinger J, Dade Lunsford L. Radiosurgery for Arteriovenous Malformations and the Impact on Headaches. Headache 2017; 57:737-745. [DOI: 10.1111/head.13055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 01/07/2017] [Accepted: 01/08/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Greg Bowden
- Center for Image-Guided Neurosurgery; University of Pittsburgh; Pittsburgh PA USA
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
| | | | - Hideyuki Kano
- Center for Image-Guided Neurosurgery; University of Pittsburgh; Pittsburgh PA USA
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
| | - Edward Monaco
- Center for Image-Guided Neurosurgery; University of Pittsburgh; Pittsburgh PA USA
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
| | - Ajay Niranjan
- Center for Image-Guided Neurosurgery; University of Pittsburgh; Pittsburgh PA USA
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
| | - John Flickinger
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
| | - L. Dade Lunsford
- Center for Image-Guided Neurosurgery; University of Pittsburgh; Pittsburgh PA USA
- Department of Radiation Oncology; University of Pittsburgh; Pittsburgh PA USA
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