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Jin H, Li Z, Gao D, Chen Y, Han H, Ma L, Yan D, Li R, Li A, Zhang H, Yuan K, Zhang Y, Zhao Y, Meng X, Li Y, Chen X, Wang H, Sun S, Zhao Y. Association of the combined stereotactic radiosurgery and embolization strategy and long-term outcomes in brain arteriovenous malformations with a volume ≤10 mL: a nationwide multicenter observational prospective cohort study. J Neurointerv Surg 2024; 16:548-554. [PMID: 37402570 DOI: 10.1136/jnis-2023-020289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/11/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND To compare the long-term outcomes of stereotactic radiosurgery (SRS) with or without prior embolization in brain arteriovenous malformations (AVMs) (volume ≤10 mL) for which SRS is indicated. METHODS Patients were recruited from a nationwide multicenter prospective collaboration registry (the MATCH study) between August 2011 and August 2021, and categorized into combined embolization and SRS (E+SRS) and SRS alone cohorts. We performed propensity score-matched survival analysis to compare the long-term risk of non-fatal hemorrhagic stroke and death (primary outcomes). The long-term obliteration rate, favorable neurological outcomes, seizure, worsened mRS score, radiation-induced changes, and embolization complications were also evaluated (secondary outcomes). Hazard ratios (HRs) were calculated using Cox proportional hazards models. RESULTS After study exclusions and propensity score matching, 486 patients (243 pairs) were included. The median (IQR) follow-up duration for the primary outcomes was 5.7 (3.1-8.2) years. Overall, E+SRS and SRS alone were similar in preventing long-term non-fatal hemorrhagic stroke and death (0.68 vs 0.45 per 100 patient-years; HR=1.46 (95% CI 0.56 to 3.84)), as well as in facilitating AVM obliteration (10.02 vs 9.48 per 100 patient-years; HR=1.10 (95% CI 0.87 to 1.38)). However, the E+SRS strategy was significantly inferior to the SRS alone strategy in terms of neurological deterioration (worsened mRS score: 16.0% vs 9.1%; HR=2.00 (95% CI 1.18 to 3.38)). CONCLUSIONS In this observational prospective cohort study, the combined strategy of E+SRS does not show substantial advantages over SRS alone. The findings do not support pre-SRS embolization for AVMs with a volume ≤10 mL.
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Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- 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
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Shanxi, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Calafiore R, Burke RM, Becerril-Gaitan A, Chen CJ, Oravec CS, Belanger K, Ding D, Yang HC, Kondziolka D, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Characterization of Pediatric Infratentorial Arteriovenous Malformations: A Retrospective, Multicenter Cohort Study. Neurosurgery 2024:00006123-990000000-01158. [PMID: 38700839 DOI: 10.1227/neu.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/11/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Infratentorial arteriovenous malformations (AVMs) harbor different characteristics compared with supratentorial AVMs. This study aims to explore the unique characteristics of pediatric infratentorial AVMs and their response to single session stereotactic radiosurgery (SRS). METHODS The International Radiosurgery Research Foundation database of pediatric patients with AVM (age <18 years) who underwent SRS was retrospectively reviewed. Baseline demographics, AVM characteristics, outcomes, and complications post-SRS were compared between infratentorial and supratentorial pediatric AVMs. Unfavorable outcome was defined as the absence of AVM obliteration, post-SRS hemorrhage, or permanent radiation-induced changes at last follow-up. RESULTS A total of 535 pediatric AVMs managed with SRS with a median follow-up of 67 months (IQR 29.0-130.6) were included, with 69 being infratentorial and 466 supratentorial. The infratentorial group had a higher proportion of deep location (58.4% vs 30.3%, P = <.001), deep venous drainage (79.8% vs 61.8%, P = .004), and prior embolization (26.1% vs 15.7%, P = .032). There was a higher proportion of hemorrhagic presentation in the infratentorial group (79.7% vs 71.3%, P = .146). There was no statistically significant difference in the odds of an unfavorable outcome (odds ratio [OR] = 1.36 [0.82-2.28]), AVM obliteration (OR = 0.85 [0.5-1.43]), post-SRS hemorrhage (OR = 0.83 [0.31-2.18]), or radiologic radiation-induced changes (OR = 1.08 [0.63-1.84]) between both cohorts. No statistically significant difference on the rates of outcomes of interest and complications were found in the adjusted model. CONCLUSION Despite baseline differences between infratentorial and supratentorial pediatric AVMs, SRS outcomes, including AVM obliteration and post-SRS hemorrhage rates, were comparable amongst both groups. SRS appears to have a similar risk profile and therapeutic benefit to infratentorial pediatric AVMs as it does for those with a supratentorial location.
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Affiliation(s)
- Rebecca Calafiore
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Rebecca M Burke
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Katherine Belanger
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville , Kentucky , USA
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York , New York , USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke , Quebec , Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherche 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 , USA
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland , Ohio , USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miami , Florida , USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
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3
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See AP, Smith ER. Management of Pediatric Intracranial Arteriovenous Malformations. J Korean Neurosurg Soc 2024; 67:289-298. [PMID: 38433517 PMCID: PMC11079567 DOI: 10.3340/jkns.2024.0027] [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: 01/23/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Pediatric intracranial arteriovenous malformations (AVMs) are challenging lesions managed by pediatric neurosurgeons. The high risk of hemorrhage and neurologic injury is compounded by the unique anatomy of each malformation that requires individualizing treatment options. This article reviews the current status of pediatric AVM epidemiology, pathophysiology and clinical care, with a specific focus on the rationale and methodology of surgical resection.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Grogan D, Dumot C, Tewari A, Mantziaris G, Dayawansa S, Schlesinger D, Sheehan J. Biologically Effective Dose and Prediction of Obliteration of Arteriovenous Malformations in Pediatric Patients Treated by Gamma Knife Radiosurgery. Neurosurgery 2024; 94:614-621. [PMID: 37830840 DOI: 10.1227/neu.0000000000002717] [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: 02/08/2023] [Accepted: 08/18/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) represents an effective treatment for pediatric arteriovenous malformations (AVMs). Biological effective dose (BED) has shown promising results in 2 previous studies as a predictive variable for outcomes in adults, but its role has never been studied in pediatric outcomes. METHODS Retrospective data for patients 18 years or younger treated with a single-session SRS for AVMs were collected from 1989 to 2019. BED calculations were performed using an α/β ratio of 2.47. Kaplan-Meier analysis was used to evaluate obliteration, new hemorrhage, and radiation-induced changes (RIC). Cox-regression analysis was used for obliteration prediction using 2 models (margin dose vs BED). RESULTS One hundred ninety-seven patients (median age = 13.1 years, IQR = 5.2) were included; 72.6% (143/197) of them presented initially with spontaneous hemorrhage. A median margin dose of 22 Gy (IQR = 4.0) with a median BED of 183.2 Gy (IQR = 70.54) was used to treat AVM with a median volume of 2.8 cm 3 (IQR = 2.9). After SRS, obliteration was confirmed in 115/197 patients (58.4%) using magnetic resonance imaging and angiography at a median follow-up of 2.85 years (IQR = 2.26). The cumulative obliteration probability was 43.6% (95% CI = 36.1-50.3), 60.5% (95% CI+ = 2.2-67.4), and 66.0% (95% CI = 56.0-73.7) at 3, 5, and 10 years, respectively. In Cox multivariate analysis, a BED >180 Gy (hazard ratio [HR] = 2.11, 95% CI = 1.30-3.40, P = .002) in model 1 and a margin dose >20 Gy (HR = 1.90, 95% CI = 1.15-3.13, P = .019) in model 2 were associated with obliteration. An AVM nidus volume >4 cm 3 was associated with lower obliteration rates in both models. The probability of symptomatic RIC at 10 years was 8.6% (95% CI = 3.5-13.4). Neither BED nor margin dose was associated with RIC occurrence, with the only predictive factor being deep AVM location (HR = 3, 95% CI = 1-9.1, P = .048). CONCLUSION This study confirms BED as a predictor for pediatric AVM obliteration. Optimization of BED in pediatric AVM SRS planning may improve cumulative obliteration rates.
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Affiliation(s)
- Dayton Grogan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
- Department of Neurological Surgery, Hospices civils de Lyon, Lyon , France
| | - Anant Tewari
- University of Virginia School of Medicine, Charlottesville , Virginia , USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Sam Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
- Department of Radiation Oncology, University of Virginia, Charlottesville , Virginia , USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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5
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González EO, Runge S, Mantziaris G, Ironside N, Sheehan JP. Stereotactic radiosurgery for brain arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia. Acta Neurochir (Wien) 2024; 166:21. [PMID: 38231447 PMCID: PMC10794397 DOI: 10.1007/s00701-024-05923-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) in patients with hereditary hemorrhagic telangiectasia (HHT) present different characteristics from sporadic AVMs, and they have lower initial bleeding rates. Conservative management is usually preferred for the treatment of these lesions. In this case study, we present the largest series of HHT patients treated with stereotactic radiosurgery to date. METHODS We identified eight patients with HHT and 14 AVMs. We retrospectively collected clinical, radiographic, and treatment characteristics of the patients and each AVM. RESULTS Most patients in our sample presented with small AVMs. The median volume of these AVMs was 0.22 cm3 (IQR 0.08-0.59). Three out of eight patients presented with initial intracerebral hemorrhage (ICH). The majority of lesions had low (12/14) Spetzler-Martin grades (I-II). Median maximum and margin doses used for treatment were 36.2 (IQR 35.25-44.4) and 20 (IQR 18-22.5) Gy, respectively. The overall obliteration rate after SRS was 11/14, and the median time to obliteration across all 11 obliterated AVMs was 35.83 months (IQR, 17-39.99). Neurological status was favorable with all patients having a mRS of 0 or 1 at the last follow-up. Symptomatic radiation-induced changes (RIC) after SRS were low (7.1%), and there were no permanent RIC. CONCLUSIONS Patients with HHT who present with multiple brain AVMs are generally well served by SRS. Obliteration can be achieved in the majority of HHT patients and with a low complication rate. In the current study, initial hemorrhage rates prior to SRS were noticeable which supports the decision to treat these AVMs. Future studies are needed to better address the role of SRS for HHT patients harboring ruptured and unruptured AVMs.
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Affiliation(s)
- Eduardo Orrego González
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Sean Runge
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA.
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6
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Beneš V, Bubeníková A, Skalický P, Bradáč O. Treatment of Brain Arteriovenous Malformations. Adv Tech Stand Neurosurg 2024; 49:139-179. [PMID: 38700684 DOI: 10.1007/978-3-031-42398-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Brain arteriovenous malformations (AVMs) are a rare entity of vascular anomalies, characteristic of anatomical shunting where arterial blood directly flows into the venous circulation. The main aim of the active treatment policy of brain AVMs is the prevention of haemorrhage. There are well-established treatment strategies that continually improve in their safety and efficacy, primarily due to the advances in imaging modalities, targeted and novel techniques, the development of alternative treatment approaches, and even better experience with the disease itself. There are interesting imaging novelties that may be prospectively applicable in the decision-making and planning of the most effective treatment approach for individual patients with intracranial AVM. Surgery is often considered the first-line treatment; however, each patient should be evaluated individually, and the risks of the active treatment policy should not overcome the benefits of the spontaneous natural history of the disease. All treatment modalities, i.e., surgery, radiosurgery, endovascular embolization, and observation, are justified but need to be meticulously selected for each individual patient in order to deliver the best treatment outcome. This chapter deals with historical and currently applied dogmas, followed by introductions of advances in each available treatment modality of AVM management.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adéla Bubeníková
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Skalický
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Rodríguez Mallma MJ, Vilca-Aguilar M, Zuloaga-Rotta L, Borja-Rosales R, Salas-Ojeda M, Mauricio D. Machine Learning Approach for Analyzing 3-Year Outcomes of Patients with Brain Arteriovenous Malformation (AVM) after Stereotactic Radiosurgery (SRS). Diagnostics (Basel) 2023; 14:22. [PMID: 38201331 PMCID: PMC10871108 DOI: 10.3390/diagnostics14010022] [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: 11/29/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
A cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels that irregularly connects arteries and veins. Stereotactic radiosurgery (SRS) has been shown to be an effective treatment for AVM patients, but the factors associated with AVM obliteration remains a matter of debate. In this study, we aimed to develop a model that can predict whether patients with AVM will be cured 36 months after intervention by means of SRS and identify the most important predictors that explain the probability of being cured. A machine learning (ML) approach was applied using decision tree (DT) and logistic regression (LR) techniques on historical data (sociodemographic, clinical, treatment, angioarchitecture, and radiosurgery procedure) of 202 patients with AVM who underwent SRS at the Instituto de Radiocirugía del Perú (IRP) between 2005 and 2018. The LR model obtained the best results for predicting AVM cure with an accuracy of 0.92, sensitivity of 0.93, specificity of 0.89, and an area under the curve (AUC) of 0.98, which shows that ML models are suitable for predicting the prognosis of medical conditions such as AVM and can be a support tool for medical decision-making. In addition, several factors were identified that could explain whether patients with AVM would be cured at 36 months with the highest likelihood: the location of the AVM, the occupation of the patient, and the presence of hemorrhage.
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Affiliation(s)
| | - Marcos Vilca-Aguilar
- Instituto de Radiocirugía del Perú, Clínica San Pablo, Lima 15023, Peru
- Servicio de Neurocirugía, Hospital María Auxiliadora, Lima 15828, Peru
| | - Luis Zuloaga-Rotta
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | - Rubén Borja-Rosales
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | | | - David Mauricio
- Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
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Pikis S, Mantziaris G, Dumot C, Shaaban A, Protopapa M, Xu Z, Niranjan A, Wei Z, Srinivasan P, Tang LW, Liscak R, May J, Martinez Moreno N, Martinez Álvarez R, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Elazzazi AH, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Lunsford D, Sheehan JP. Third Stereotactic Radiosurgery for Residual Arteriovenous Malformations: A Retrospective Multicenter Study. Neurosurgery 2023:00006123-990000000-01004. [PMID: 38108313 DOI: 10.1227/neu.0000000000002805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no studies evaluating the efficacy and safety of more than 2 stereotactic radiosurgery (SRS) procedures for cerebral arteriovenous malformations (AVM). The aim of this study was to provide evidence on the role of third single-session SRS for AVM residual. METHODS This multicenter, retrospective study included patients managed with a third single-session SRS procedure for an AVM residual. The primary study outcome was defined as AVM nidus obliteration without AVM bleeding or symptomatic radiation-induced changes (RIC). Secondary outcomes evaluated were AVM obliteration, AVM hemorrhage, asymptomatic, and symptomatic RIC. RESULTS Thirty-eight patients (20/38 [52.6%] females, median age at third SRS 34.5 [IQR 20] years) were included. The median clinical follow-up was 46 (IQR 14.8) months, and 17/38 (44.7%) patients achieved favorable outcome. The 3-year and 5-year cumulative probability rates of favorable outcome were 23% (95% CI = 10%-38%) and 53% (95% CI = 29%-73%), respectively. The cumulative probability of AVM obliteration at 3 and 5 years after the third SRS was 23% (95% CI = 10%-37%) and 54% (95% CI = 29%-74%), respectively. AVM bleeding occurred in 2 patients, and 1 of them underwent subsequent resection. The cumulative probability rate of post-SRS AVM hemorrhage remained constant at 5.3% (95% CI = 1%-16%) during the first 5 years of follow-up. Transient symptomatic RIC managed conservatively occurred in 5/38 patients (13.2%) at a median time of 12.5 (IQR 22.5) months from third SRS. Radiation-induced cyst formation was noted in 1 patient (4.2%) 19 months post-SRS. No mortality, radiation-associated malignancy, or permanent symptomatic RIC was noted during follow-up. CONCLUSION A third single-session SRS to treat a residual intracranial AVM offers obliteration in most patients. The risk of RIC was low, and these effects were transient. While not often required, a third SRS can be performed in patients with persistent residual AVMs.
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Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
| | - Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Maria Protopapa
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Priyanka Srinivasan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lilly W Tang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Hesham Elazzazi
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Francis J Jareczek
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James McInerney
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Lee J, Kim WC, Kim HJ, Park H. CyberKnife based fractionated stereotactic radiotherapy as an upfront treatment for cerebral arteriovenous malformation. J Clin Neurosci 2023; 117:40-45. [PMID: 37757652 DOI: 10.1016/j.jocn.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND To explore the therapeutic outcomes of CyberKnife based fractionated stereotactic radiotherapy (CKFRT) for patients with cerebral arteriovenous malformations (AVM). METHODS Between January 2008 and October 2020, 45 patients underwent CKFRT for cerebral AVMs as a first treatment. The delineation of AVM targets included AVM nidus. The mean target volume was 4.07 cm3, and 9 lesions (20%) were larger than 10.0 cm3. The mean marginal dose was 24 Gy (range, 20-35 Gy). CKFRT was delivered in median 3 fractions (range, 2 ∼ 5 fractions). AVM obliteration following CKFRT was confirmed by magnetic resonance imaging or angiography. RESULTS During a median follow-up of 47 (5-148) months, complete obliteration and partial obliteration of AVM after CKFRT were obtained in 23 (51%) and 13 (29%) patients, respectively. Median time to complete obliteration was 39 (15-63) months. The cumulative probability of complete obliteration rate at 3 years was 47%. Complete obliteration rate of AVM was associated with Radiosurgery-based AVM score, which was consisted of AVM volume, patients age, and AVM location. One (2%) patient had hemorrhage during the follow-up period. CONCLUSIONS CKFRT is an effective primary treatment for patients with cerebral AVMs with a low hemorrhage risk.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea.
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - Hyeonseon Park
- Department of Neurosurgery, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea.
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10
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See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA.
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11
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Gilotra K, Swarna S, Mani R, Basem J, Dashti R. Role of artificial intelligence and machine learning in the diagnosis of cerebrovascular disease. Front Hum Neurosci 2023; 17:1254417. [PMID: 37746051 PMCID: PMC10516608 DOI: 10.3389/fnhum.2023.1254417] [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: 07/07/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Cerebrovascular diseases are known to cause significant morbidity and mortality to the general population. In patients with cerebrovascular disease, prompt clinical evaluation and radiographic interpretation are both essential in optimizing clinical management and in triaging patients for critical and potentially life-saving neurosurgical interventions. With recent advancements in the domains of artificial intelligence (AI) and machine learning (ML), many AI and ML algorithms have been developed to further optimize the diagnosis and subsequent management of cerebrovascular disease. Despite such advances, further studies are needed to substantively evaluate both the diagnostic accuracy and feasibility of these techniques for their application in clinical practice. This review aims to analyze the current use of AI and MI algorithms in the diagnosis of, and clinical decision making for cerebrovascular disease, and to discuss both the feasibility and future applications of utilizing such algorithms. Methods We review the use of AI and ML algorithms to assist clinicians in the diagnosis and management of ischemic stroke, hemorrhagic stroke, intracranial aneurysms, and arteriovenous malformations (AVMs). After identifying the most widely used algorithms, we provide a detailed analysis of the accuracy and effectiveness of these algorithms in practice. Results The incorporation of AI and ML algorithms for cerebrovascular patients has demonstrated improvements in time to detection of intracranial pathologies such as intracerebral hemorrhage (ICH) and infarcts. For ischemic and hemorrhagic strokes, commercial AI software platforms such as RapidAI and Viz.AI have bene implemented into routine clinical practice at many stroke centers to expedite the detection of infarcts and ICH, respectively. Such algorithms and neural networks have also been analyzed for use in prognostication for such cerebrovascular pathologies. These include predicting outcomes for ischemic stroke patients, hematoma expansion, risk of aneurysm rupture, bleeding of AVMs, and in predicting outcomes following interventions such as risk of occlusion for various endovascular devices. Preliminary analyses have yielded promising sensitivities when AI and ML are used in concert with imaging modalities and a multidisciplinary team of health care providers. Conclusion The implementation of AI and ML algorithms to supplement clinical practice has conferred a high degree of accuracy, efficiency, and expedited detection in the clinical and radiographic evaluation and management of ischemic and hemorrhagic strokes, AVMs, and aneurysms. Such algorithms have been explored for further purposes of prognostication for these conditions, with promising preliminary results. Further studies should evaluate the longitudinal implementation of such techniques into hospital networks and residency programs to supplement clinical practice, and the extent to which these techniques improve patient care and clinical outcomes in the long-term.
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Affiliation(s)
| | | | | | | | - Reza Dashti
- Dashti Lab, Department of Neurological Surgery, Stony Brook University Hospital, Stony Brook, NY, United States
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12
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Sattari SA, Shahbandi A, Kim JE, Lee RP, Feghali J, Hung A, Yang W, Rincon-Torroella J, Xu R, Caplan JM, Gonzalez LF, Tamargo RJ, Huang J. Microsurgery Versus Stereotactic Radiosurgery for Treatment of Patients With Brain Arteriovenous Malformation: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 93:510-523. [PMID: 36999929 DOI: 10.1227/neu.0000000000002460] [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: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial. OBJECTIVE To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs. METHOD Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence. RESULTS Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P < .000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P = .04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P = .0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P = .52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P = .53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P = .77, evidence: moderate) were comparable between the groups. CONCLUSION Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ataollah Shahbandi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
- Tehran School of Medicine, Tehran University of Medical Science, Tehran , Iran
| | - Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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13
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He Z, Ho MKJ, Lee WYV, Law HY, Wong YWV, Leung TW, Mui WH, Wong ST, Wong CSF, Yam KY. Frameless versus frame-based stereotactic radiosurgery for intracranial arteriovenous malformations: A propensity-matched analysis. Clin Transl Radiat Oncol 2023; 41:100642. [PMID: 37304170 PMCID: PMC10248791 DOI: 10.1016/j.ctro.2023.100642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
Objective The frameless linear accelerator (LINAC) based stereotactic radiosurgery (SRS) has been evolving with a reduction in patient discomfort. However, there was limited evidence comparing frame-based and frameless SRS for intracranial arteriovenous malformations (AVM). We aimed to compare the treatment outcomes between frame-based and frameless LINAC SRS. Materials and Methods This retrospective cohort compared the outcomes of frame-based LINAC SRS (1998-2009) with frameless LINAC SRS (2010-2020). The primary outcome was the obliteration rate. The other outcomes included the neurological, radiological, and functional outcomes after SRS. A matched cohort was identified by propensity scores for further comparisons. Results A total of 65 patients were included with a mean follow-up time of 13.2 years (158.5 months). There were 40 patients in the frame-based group and 25 patients in the frameless group. The overall obliteration rate was comparable (Frame-based 82.5% vs Frameless 80.0%, p = 0.310) and not significantly different over time (log-rank p = 0.536). The crude post-SRS hemorrhage rate was 1.5% and the incidence was 0.3 per 100 person-years. There were 67.7% of patients with AVM obliteration without new persistent neurological deficits at the last visit and 56.9% of patients with AVM obliteration without any deficits (transient or persistent) during the entire follow-up period. Four patients (8.0%) developed late onset persistent adverse radiation effects (more than 96 months after SRS) among 50 patients with more than 8-year surveillance. In the propensity-matched cohort of 42 patients, there was no significant difference in AVM obliteration (Frame-based vs Frameless, log-rank p = 0.984). Conclusion Frameless and frame-based LINAC SRS have comparable efficacy in intracranial AVM obliteration. A longer follow-up duration may further characterize the rate of late adverse radiation effects in frameless SRS.
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Affiliation(s)
- Zhexi He
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Man Kit Jason Ho
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wan Yan Venus Lee
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Hing Yuen Law
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Yee Wa Victy Wong
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - To-wai Leung
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wing Ho Mui
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Sui-To Wong
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | | | - Kwong Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
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14
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Borius PY, Januel AC, Plas JY, Duthil P, Lotterie JA, Latorzeff I, Sabatier J. Long-term follow-up of an overexposure radiation incident in a cohort treated with linear accelerator-based stereotactic radiosurgery for intracranial arteriovenous malformations. J Neurosurg 2023; 138:1615-1621. [PMID: 36433879 DOI: 10.3171/2022.10.jns221763] [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: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Dosimetric radiosurgery incidents are rare and probably insufficiently reported in scientific publications. After a long follow-up (FU), the authors studied the outcomes of patients treated with overexposure radiation for arteriovenous malformation (AVM) administered via stereotactic radiosurgery (SRS) at their department. METHODS Between May 2006 and June 2007, 22 patients were treated for AVM with SRS. The mean (range) patient age was 43.5 (11.8-78) years. Previous treatments were embolization (n = 10), SRS (1), and surgery (1). The average (range) volume was 2.1 (0.2-6.4) cm3. The median prescribed minimal dose was 18.0 Gy. An initial error in the estimation of scatter factors led to overexposure to radiation. Due to this incident, the median delivered minimum dose was 25.0 Gy. All patients were prospectively followed with clinical examination and imaging. RESULTS The mean (range) clinical FU was 14.5 (12.0-15.2) years. AVM obliteration after SRS was completed in 90.9% of patients at a mean (range) of 39.4 (24.4-70.4) months. No patient had post-SRS AVM bleeding. Three patients (13.6%) had new permanent deficits due to radiation-induced changes (RICs). Obliteration without new deficits was achieved in 18 patients (81.8%). Two patients had new epilepsy that was probably due to RIC but well controlled. The median (range) MRI FU was 13.8 (2.5-14.9) years. During MRI FU, two RIC periods were observed: one classic period during the first 3 years showed T1-weighted annular irregular enhancement (13%), and the other period between 5 and 15 years after SRS showed the occurrence of cystic and hemorrhagic lesions (22.7%). There were no cases of radiation-induced tumor. CONCLUSIONS The present long-term report showed that this overexposure incident probably increased the AVM obliteration rate. This overexposure seems to have induced RIC and in particular a higher rate of cystic and hemorrhagic late lesions with nevertheless moderate clinical consequences. Long-term FU for AVM is mandatory due to the risk of late RIC.
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Affiliation(s)
- Pierre-Yves Borius
- 1Neurosurgery Department and Radiosurgery Department, Pitié Salpêtrière-Sorbonne University Hospital, Paris, France
- Departments of2Neurosurgery and Radiosurgery
| | | | | | - Pierre Duthil
- Departments of2Neurosurgery and Radiosurgery
- 5Medical Physics, Toulouse University Hospital, Toulouse, France; and
| | | | - Igor Latorzeff
- Departments of2Neurosurgery and Radiosurgery
- 4Department of Radiotherapy-Oncology, Pasteur Clinic, Toulouse, France
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15
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Shahbandi A, Sattari SA, Haghshomar M, Shab-Bidar S, Lawton MT. Application of diffusion tensor-based tractography in treatment of brain arteriovenous malformations: a systematic review. Neurosurg Rev 2023; 46:115. [PMID: 37162690 DOI: 10.1007/s10143-023-02017-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/11/2023]
Abstract
There is no systematic review investigating the utility of Diffusion tensor-based tractography findings for treating brain arteriovenous malformations (bAVMs). This systematic review aims to investigate the outcomes following bAVM treatment when tractography data is incorporated into treatment planning. PubMed/MEDLINE, Scopus, and Cochrane Library, were searched for published studies. Prospective or retrospective studies involving at least one patient with confirmed bAVM and available data on tractography and clinical outcomes were included. A total of 16 studies were eligible for this review, consisting of 298 patients. 48.2% of patients were female. The mean age of the patients was 27.5 years (range: 5-77). Stereotactic radiosurgery (SRS) and microsurgical resection each were the treatment of choice in eight studies, respectively. Two-hundred forty-eight patients underwent SRS as the primary treatment, while microsurgery was used to resect the bAVMs in 50 patients. The corticospinal tract, optic pathway, and arcuate fasciculus were the most widely investigated white matter tracts. Tractography disruption and failure frequencies were 19.1% and 1.8%, respectively. The pooled proportions (95% CI) of obliteration rates were 88.78% (73.51-95.76) for microsurgery and 51.45% (13-17-88.10) following SRS. Treatment-related non-hemorrhagic complications rates occurred in 24.2% and 9.9% of patients who underwent microsurgical resection and SRS, respectively. Tractography findings can contribute to providing a more accurate dosimetry analysis of functional white matter tracts at risk prior to SRS and minimizing the surgical morbidity following microsurgical resection.
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Affiliation(s)
- Ataollah Shahbandi
- School of Medicine, Tehran University of Medical Sciences, Enghelab Street, Tehran, Iran
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sakineh Shab-Bidar
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA.
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16
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Naylor RM, Graffeo CS, Nesvick CL, Link MJ, Brown PD, Stafford SL, Laack NN, Pollock BE. Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system. J Neurosurg 2023; 138:804-809. [PMID: 35901695 DOI: 10.3171/2022.5.jns22761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV-V) AVMs to enable comparison with published microsurgical series. METHODS In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV-V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV-V AVMs. RESULTS AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38). CONCLUSIONS The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of "inoperable" AVMs according to Supp-SM grade (≥ 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.
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Affiliation(s)
- Ryan M Naylor
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Christopher S Graffeo
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Cody L Nesvick
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott L Stafford
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N Laack
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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17
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Chen Y, Han H, Meng X, Jin H, Gao D, Ma L, Li R, Li Z, Yan D, Zhang H, Yuan K, Wang K, Zhang Y, Zhao Y, Jin W, Li R, Lin F, Chao X, Lin Z, Hao Q, Wang H, Ye X, Kang S, Li Y, Sun S, Liu A, Wang S, Zhao Y, Chen X. Development and Validation of a Scoring System for Hemorrhage Risk in Brain Arteriovenous Malformations. JAMA Netw Open 2023; 6:e231070. [PMID: 36857052 PMCID: PMC9978947 DOI: 10.1001/jamanetworkopen.2023.1070] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
IMPORTANCE The dilemma between natural rupture risk and adverse outcomes of intervention is of major concern for patients with unruptured arteriovenous malformations (AVMs). The existing risk score for AVM rupture includes factors that are controversial and lacks prospective validation. OBJECTIVE To develop and robustly validate a reliable scoring system to predict the rupture risk of AVMs. DESIGN, SETTING, AND PARTICIPANTS This prognostic study developed a prediction model derived from a single-center cohort (derivation cohort) and validated in a multicenter external cohort (multicenter external validation cohort) and a cohort of patients receiving conservative treatment management (conservative treatment validation cohort). Patients were recruited from a nationwide multicenter prospective collaboration registry in China. A total of 4135 patients were enrolled in the registry between August 1, 2011, and September 1, 2021. Of those, 3962 patients were included in the study (3585 in the derivation cohort and 377 in the multicenter external validation cohort); 1028 patients from the derivation cohort who had time-to-event data and prerupture imaging results were included in the conservative treatment validation cohort. Data were analyzed from March 10 to June 21, 2022. MAIN OUTCOMES AND MEASURES A scoring system was developed based on risk factors identified from a literature review and a robust selection process. Patients were stratified into different risk groups based on scores to calculate hemorrhage-free probability in future years, and Kaplan-Meier curves were plotted to visualize risk stratification. Receiver operating characteristic curves were used to assess the discrimination of models. Univariable analyses (logistic regression analysis for descriptive data and Cox regression analysis for survival data) were used to compare baseline information and assess bias. RESULTS Among 3962 patients (2311 men [58.3%]; median [IQR] age, 26.1 [14.6-35.5] years), 3585 patients (2100 men [58.6%]; median [IQR] age, 25.9 [14.6-35.0] years) were included in the derivation cohort, and 377 patients (211 men [56.0%]; median [IQR] age, 26.4 [14.5-39.2] years) were included in the multicenter external validation cohort. Thirty-six hemorrhages occurred over a median (IQR) follow-up of 4.2 (0.3-6.0) years among 1028 patients in the conservative treatment validation cohort. Four risk factors were used to develop the scoring system: ventricular system involvement, venous aneurysm, deep location, and exclusively deep drainage (VALE). The VALE scoring system performed well in all 3 cohorts, with areas under the receiver operating characteristic curve of 0.77 (95% CI, 0.75-0.78) in the derivation cohort, 0.85 (95% CI, 0.81-0.89) in the multicenter external validation cohort, and 0.73 (95% CI, 0.65-0.81) in the conservative treatment validation cohort. The 10-year hemorrhage-free rate was 95.5% (95% CI, 87.1%-100%) in the low-risk group, 92.8% (95% CI, 88.8%-97.0%) in the moderate-risk group, and 75.8% (95% CI, 65.1%-88.3%) in the high-risk group; the model discrimination was significant when comparing these rates between the high-risk group and the low- and moderate-risk groups (P < .001 for both comparisons). CONCLUSIONS AND RELEVANCE In this prognostic study, the VALE scoring system was developed to distinguish rupture risk among patients with AVMs. The stratification of unruptured AVMs may enable patients with low risk of rupture to avoid unnecessary interventions. These findings suggest that the scoring system is a reliable and applicable tool that can be used to facilitate patient and physician decision-making and reduce unnecessary interventions or unexpected AVM ruptures.
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Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Hebei, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Gamma Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Shanxi, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaofeng Chao
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical University, Jiangsu, China
| | - Zhengfeng Lin
- Department of Neurosurgery, The First People's Hospital of Qinzhou, Guangxi, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Gamma Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Gamma Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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18
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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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19
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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Compactness index: a radiosurgery outcome predictor for patients with unruptured brain arteriovenous malformations. J Neurosurg 2023; 138:241-250. [PMID: 35594883 DOI: 10.3171/2022.4.jns212369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 04/07/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of the study was to define and quantify brain arteriovenous malformation (bAVM) compactness and to assess its effect on outcomes after Gamma Knife radiosurgery (GKRS) for unruptured bAVMs. METHODS Unsupervised machine learning with fuzzy c-means clustering was used to differentiate the tissue constituents of bAVMs on T2-weighted MR images. The percentages of vessel, brain, and CSF were quantified. The proposed compactness index, defined as the ratio of vasculature tissue to brain tissue, categorized bAVM morphology into compact, intermediate, and diffuse types according to the tertiles of this index. The outcomes of interest were complete obliteration and radiation-induced changes (RICs). RESULTS A total of 209 unruptured bAVMs treated with GKRS were retrospectively included. The median imaging and clinical follow-up periods were 49.2 and 72.3 months, respectively. One hundred seventy-three bAVMs (82.8%) achieved complete obliteration after a median latency period of 43.3 months. The rates of RIC and permanent RIC were 76.1% and 3.8%, respectively. Post-GKRS hemorrhage occurred in 14 patients (6.7%), resulting in an annual bleeding risk of 1.0%. Compact bAVM, smaller bAVM volume, and exclusively superficial venous drainage were independent predictors of complete obliteration. Diffuse bAVM morphology, larger bAVM volume, and higher margin dose were independently associated with RICs. CONCLUSIONS The compactness index quantitatively describes the compactness of unruptured bAVMs. Moreover, compact bAVMs may have a higher obliteration rate and a smaller risk of RICs than diffuse bAVMs. This finding could help guide decision-making regarding GKRS treatment for patients with unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Syu-Jyun Peng
- 2Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei
| | - David Hung-Chi Pan
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Jo-Ting Tsai
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,11Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,13Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Cheng-Ying Shiau
- 8Cancer Center, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - I-Chang Su
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hsiu-Mei Wu
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,5Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wan-Yuo Guo
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wei-Lun Lo
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Shao-Wen Lai
- 15Product and Engineering, Zippin, San Carlos, California
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei.,10Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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20
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Ung TH, Belanger K, Hashmi A, Sekar V, Meola A, Chang SD. Microenvironment changes in arteriovenous malformations after stereotactic radiation. Front Hum Neurosci 2022; 16:982190. [PMID: 36590065 PMCID: PMC9797682 DOI: 10.3389/fnhum.2022.982190] [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: 06/30/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Cerebral arteriovenous malformations are dysplastic vascular tangles with aberrant vascular dynamics and can result significant morbidity and mortality. A myriad of challenges are encountered when treating these lesions and are largely based on nidal size, location, and prior hemorrhage. Currently, stereotactic radiosurgery is an accepted form of treatment for small to medium sized lesions and is especially useful in the treatment of lesions in non-surgically assessable eloquent areas of the brain. Despite overall high rates of nidal obliteration, there is relatively limited understand on the mechanisms that drive the inflammatory and obliterative pathways observed after treatment with stereotactic radiosurgery. This review provides an overview of arteriovenous malformations with respect to stereotactic radiosurgery and the current understanding of the mechanisms that lead to nidal obliteration.
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Affiliation(s)
- Timothy H. Ung
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States,Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States,*Correspondence: Timothy H. Ung
| | - Katherine Belanger
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ayesha Hashmi
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Vashisht Sekar
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Antonio Meola
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Steven D. Chang
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
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21
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State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations-A Systematic Review. J Clin Med 2022; 11:jcm11237208. [PMID: 36498782 PMCID: PMC9739246 DOI: 10.3390/jcm11237208] [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: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
As a significant cause of intracerebral hemorrhages, seizures, and neurological decline, brain arteriovenous malformations (bAVMs) are a rare group of complex vascular lesions with devastating implications for patients' quality of life. Although the concerted effort of the scientific community has improved our understanding of bAVM biology, the exact mechanism continues to be elucidated. Furthermore, to this day, due to the high heterogeneity of bAVMs as well as the lack of objective data brought by the lack of evaluative and comparative studies, there is no clear consensus on the treatment of this life-threatening and dynamic disease. As a consequence, patients often fall short of obtaining the optimal treatment. Endovascular embolization is an inherent part of multidisciplinary bAVM management that can be used in various clinical scenarios, each with different objectives. Well-trained neuro-interventional centers are proficient at curing bAVMs that are smaller than 3 cm; are located superficially in noneloquent areas; and have fewer, larger, and less tortuous feeding arteries. The transvenous approach is an emerging effective and safe technique that potentially offers a chance to cure previously untreatable bAVMs. This review provides the state of the art in all aspects of endovascular embolization in the management of bAVMs.
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22
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Becerril-Gaitan A, Ironside N, Chen CJ, Ding D. Commentary: Risk for Hemorrhage the First 2 Years After Gamma Knife Surgery for Arteriovenous Malformations: An Update. Neurosurgery 2022; 91:e153-e154. [PMID: 36250710 DOI: 10.1227/neu.0000000000002179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
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23
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Abbas R, Al-Saiegh F, Atallah E, Naamani KE, Tjoumakaris S, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH. Treatment of Intracerebral Vascular Malformations: When to Intervene. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00739-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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24
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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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25
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Niwa R, Ichi S, Nomura R, Sato K. Hypofractionated Stereotactic Radiotherapy with CyberKnife for Large Arteriovenous Malformations and Arteriovenous Malformations Located in Eloquent Areas. Neurol Med Chir (Tokyo) 2022; 62:445-450. [PMID: 36070959 PMCID: PMC9637402 DOI: 10.2176/jns-nmc.2022-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Literature has yet to establish an appropriate treatment strategy for large arteriovenous malformations (AVMs) and AVMs located in eloquent areas. In this study, the treatment outcomes of hypofractionated stereotactic radiotherapy (HSRT) with CyberKnife (CK) for large AVMs and AVMs in eloquent areas were evaluated. This study retrospectively evaluated 38 consecutive patients with AVMs treated with HSRT in the Japanese Red Cross Medical Center between August 2010 and July 2015. Obliteration rates and hemorrhage rates at 3- and 5-years of follow-up were calculated. Factors for hemorrhage and obliteration were analyzed with logistic regression analysis. Fourteen (36.8%) patients had a history of hemorrhage. Twenty (52.6%) AVMs were larger than 10 mL, and 34 (89.5%) AVMs were located in eloquent areas. The majority of the AVMs (84.2%) were classified into high grades (grades 3, 4, and 5) using the Spetzler-Martin grading scale. The median modified radiosurgery-based AVM score was 2.05, and the median Virginia Radiosurgery AVM Score was 3. The mean marginal dose was 24.5 ± 2.5 Gy. Twenty-three and 15 patients received three- and five-fraction stereotactic radiotherapy, respectively. At 3 and 5 years posttreatment, two (2.0%/year) and six (6.7%/year) patients had hemorrhage with obliteration rates of 15.2% and 16.7%, respectively. AVM localization in eloquent areas was a risk factor for obliteration failure. This study revealed that HSRT with CK for large AVMs and AVMs located in eloquent areas contributed to hemorrhage risk reduction and obliteration, at least in the early stages.
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Affiliation(s)
- Ryoko Niwa
- CyberKnife Center, Japanese Red Cross Medical Center.,Department of Neurosurgery, The University of Tokyo Hospital
| | - Shunsuke Ichi
- CyberKnife Center, Japanese Red Cross Medical Center
| | - Ryutaro Nomura
- CyberKnife Center, Japanese Red Cross Medical Center.,CyberKnife Center, Chigasaki Chuo Hospital
| | - Kengo Sato
- CyberKnife Center, Japanese Red Cross Medical Center
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26
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Alzate JD, Berger A, Bernstein K, Mullen R, Qu T, Silverman JS, Shapiro M, Nelson PK, Raz E, Jafar JJ, Riina HA, Kondziolka D. Preoperative flow analysis of arteriovenous malformations and obliteration response after stereotactic radiosurgery. J Neurosurg 2022; 138:944-954. [PMID: 36057117 DOI: 10.3171/2022.7.jns221008] [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: 04/29/2022] [Accepted: 07/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Morphological and angioarchitectural features of cerebral arteriovenous malformations (AVMs) have been widely described and associated with outcomes; however, few studies have conducted a quantitative analysis of AVM flow. The authors examined brain AVM flow and transit time on angiograms using direct visual analysis and a computer-based method and correlated these factors with the obliteration response after Gamma Knife radiosurgery. METHODS A retrospective analysis was conducted at a single institution using a prospective registry of patients managed from January 2013 to December 2019: 71 patients were analyzed using a visual method of flow determination and 38 were analyzed using a computer-based method. After comparison and validation of the two methods, obliteration response was correlated to flow analysis, demographic, angioarchitectural, and dosimetric data. RESULTS The mean AVM volume was 3.84 cm3 (range 0.64-19.8 cm3), 32 AVMs (45%) were in critical functional locations, and the mean margin radiosurgical dose was 18.8 Gy (range 16-22 Gy). Twenty-seven AVMs (38%) were classified as high flow, 37 (52%) as moderate flow, and 7 (10%) as low flow. Complete obliteration was achieved in 44 patients (62%) at the time of the study; the mean time to obliteration was 28 months for low-flow, 34 months for moderate-flow, and 47 months for high-flow AVMs. Univariate and multivariate analyses of factors predicting obliteration included AVM nidus volume, age, and flow. Adverse radiation effects were identified in 5 patients (7%), and 67 patients (94%) remained free of any functional deterioration during follow-up. CONCLUSIONS AVM flow analysis and categorization in terms of transit time are useful predictors of the probability of and the time to obliteration. The authors believe that a more quantitative understanding of flow can help to guide stereotactic radiosurgery treatment and set accurate outcome expectations.
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Affiliation(s)
| | | | | | | | | | | | - Maksim Shapiro
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
| | - Peter K Nelson
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
| | - Eytan Raz
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
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27
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Shinya Y, Hasegawa H, Shin M, Kawashima M, Koizumi S, Katano A, Suzuki Y, Kashiwabara K, Saito N. Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes. Neurosurgery 2022; 91:485-495. [PMID: 35876672 DOI: 10.1227/neu.0000000000002064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) of the diencephalon (DC) and brainstem (BS) are difficult to treat. Stereotactic radiosurgery (SRS) is a reasonable option; however, an optimal radiosurgical dose needs to be established to optimize long-term outcomes. OBJECTIVE To evaluate dose-dependent long-term outcomes of SRS for DC/BS-AVMs. METHODS We retrospectively analyzed the long-term outcomes of 118 patients who had SRS-treated DC/BS-AVMs. The outcomes included post-SRS hemorrhage, AVM obliteration, neurological outcomes, and disease-specific survival. According to margin doses, the patients were classified into low (<18 Gy), medium (18-20 Gy), and high (>20 Gy) dose groups. RESULTS SRS reduced the annual hemorrhage rate from 8.6% to 1.6% before obliteration and 0.0% after obliteration. The cumulative hemorrhage rate in the low dose group was likely to be higher than that in the other groups ( P = .113). The cumulative obliteration rates in the entire cohort were 74% and 83% at 5 and 10 years, respectively, and were significantly lower in the low dose group than in the other groups (vs medium dose: P = .027, vs high dose: P = .016). Multivariate analyses demonstrated that low dose SRS was significantly associated with worse obliteration rates (hazard ratio 0.18, 95% CI 0.04-0.79; P = .023). CONCLUSION SRS with a margin dose of 18 to 20 Gy for DC/BS-AVMs may be optimal, providing a higher obliteration rate and lower risk of post-SRS hemorrhage than lower dose SRS. Dose reduction to <18 Gy should only be optional when higher doses are intolerable.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kosuke Kashiwabara
- Biostatistics Division, Central Coordinating Unit, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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28
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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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29
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Hasegawa H, Shin M, Kawagishi J, Jokura H, Hasegawa T, Kato T, Kawashima M, Shinya Y, Kenai H, Kawabe T, Sato M, Serizawa T, Nagano O, Aoyagi K, Kondoh T, Yamamoto M, Onoue S, Nakazaki K, Iwai Y, Yamanaka K, Hasegawa S, Kashiwabara K, Saito N. A Practical Grading Scale for Predicting Outcomes of Radiosurgery for Dural Arteriovenous Fistulas: JLGK 1802 Study. J Stroke 2022; 24:278-287. [PMID: 35677982 PMCID: PMC9194540 DOI: 10.5853/jos.2021.03594] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/16/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose To assess the long-term outcomes of intracranial dural arteriovenous fistula (DAVF) treated with stereotactic radiosurgery (SRS) alone or embolization and SRS (Emb-SRS) and to develop a grading system for predicting DAVF obliteration.
Methods This multi-institutional retrospective study included 200 patients with DAVF treated with SRS or Emb-SRS. We investigated the long-term obliteration rate and obliteration-associated factors. We developed a new grading system to estimate the obliteration rate. Additionally, we compared the outcomes of SRS and Emb-SRS by using propensity score matching.
Results The 3- and 4-year obliteration rates were 66.3% and 78.8%, respectively. The post-SRS hemorrhage rate was 2%. In the matched cohort, the SRS and Emb-SRS groups did not differ in the rates of obliteration (P=0.54) or post-SRS hemorrhage (P=0.50). In multivariable analysis, DAVF location and cortical venous reflux (CVR) were independently associated with obliteration. The new grading system assigned 2, 1, and 0 points to DAVFs in the anterior skull base or middle fossa, DAVFs with CVR or DAVFs in the superior sagittal sinus or tentorium, and DAVFs without these factors, respectively. Using the total points, patients were stratified into the highest (0 points), intermediate (1 point), or lowest (≥2 points) obliteration rate groups that exhibited 4-year obliteration rates of 94.4%, 71.3%, and 60.4%, respectively (P<0.01).
Conclusions SRS-based therapy achieved DAVF obliteration in more than three-quarters of the patients at 4 years of age. Our grading system can stratify the obliteration rate and may guide physicians in treatment selection.
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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
| | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | | | - Takenori Kato
- Department of Neurosurgery, Komaki City Hospital, Komaki, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroyuki Kenai
- Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan
| | - Takuya Kawabe
- Kyoto Gamma Knife Center, Rakusai Shimizu Hospital, Kyoto, Japan
| | - Manabu Sato
- Kyoto Gamma Knife Center, Rakusai Shimizu Hospital, Kyoto, Japan
| | - Toru Serizawa
- Tokyo Gamma Unit Center, Tsukiji Neurological Clinic, Tokyo, Japan
| | - Osamu Nagano
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
| | - Kyoko Aoyagi
- Gamma Knife House, Chiba Cerebral and Cardiovascular Center, Ichihara, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, Kobe, Japan
| | | | - Shinji Onoue
- Department of Neurosurgery, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Kiyoshi Nakazaki
- Department of Neurosurgery, Brain Attack Center, Ota Memorial Hospital, Fukuyama, Japan
| | - Yoshiyasu Iwai
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Kazuhiro Yamanaka
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Seiko Hasegawa
- Department of Neurosurgery, Kuroishi General Hospital, Kuroishi, Japan
| | - Kosuke Kashiwabara
- Data Science Office, Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
- Correspondence: Masahiro Shin Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan Tel: +81-3-5800-8853 Fax: +81-3-5800-8655 E-mail:
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30
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Pérez-Alfayate R, Grasso G. State of the Art and Future Direction in Diagnosis, Molecular Biology, Genetics, and Treatment of Brain Arteriovenous Malformations. World Neurosurg 2022; 159:362-372. [PMID: 35255635 DOI: 10.1016/j.wneu.2021.08.111] [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: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are uncommon and represent a heterogeneous group of lesions. Although these 2 facts have delayed research on this topic, knowledge about the pathophysiology, diagnosis, and treatment of bAVMs has evolved in recent years. We conducted a review of the literature to update the knowledge about diagnosis, molecular biology, genetic, pathology, and treatment by searching for the following terms: "Epidemiology AND Natural History," "risk of hemorrhage," "intracranial hemorrhage," "diagnosis," "angiogenesis," "molecular genetics," "VEGF," "KRAS," "radiosurgery," "endovascular," "microsurgery," or "surgical resection." Our understanding of bAVMs has significantly evolved in recent years. The latest investigations have helped in defining some molecular pathways involved in the pathology of bAVM. Although there is still more to learn and discover, describing these pathways will allow the creation of targeted treatments that could improve the prognosis of patients with bAVMs.
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Affiliation(s)
- Rebeca Pérez-Alfayate
- Department of Neurosurgery, Neuroscience Institute, Hospital Clínico San Carlos, Madrid, Spain.
| | - Giovanni Grasso
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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31
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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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32
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Yan D, Chen Y, Li Z, Zhang H, Li R, Yuan K, Han H, Meng X, Jin H, Gao D, Li Y, Sun S, Liu A, Chen X, Zhao Y. Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis. Front Neurol 2021; 12:752164. [PMID: 34712200 PMCID: PMC8545857 DOI: 10.3389/fneur.2021.752164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: Whether partial embolization could facilitate the post-stereotactic radiosurgery (SRS) obliteration for brain arteriovenous malformations (bAVMs) remains controversial. We performed this study to compare the outcomes of SRS with and without prior embolization for bAVMs. Methods: We retrospectively reviewed the Beijing Tiantan AVMs prospective registration research database from September 2011 to October 2014. Patients were categorized into two groups, combined upfront embolization and SRS (Em+SRS group) and SRS alone (SRS group), and we performed a propensity score matching analysis based on pre-embolization baseline characteristics; the matched groups each comprised 76 patients. Results: The obliteration rate was similar between SRS and Em+SRS (44.7 vs. 31.6%; OR, 1.754; 95% CI, 0.905–3.401; p = 0.096). However, the SRS group was superior to the Em+SRS group in terms of cumulative obliteration rate at a follow-up of 5 years (HR,1.778; 95% CI, 1.017–3.110; p = 0.033). The secondary outcomes, including functional state, post-SRS hemorrhage, all-cause mortality, and edema or cyst formation were similar between the matched cohorts. In the ruptured subgroup, the SRS group could achieve higher obliteration rate than Em+SRS group (56.5 vs. 31.9%; OR, 2.773; 95% CI, 1.190–6.464; p = 0.018). The cumulative obliteration rate at 5 years was also higher in the SRS group (64.5 vs. 41.3%; HR, 2.012; 95% CI, 1.037–3.903; p = 0.038), and the secondary outcomes were also similar between the matched cohorts. Conclusion: Although there was no significant difference in the overall obliteration rate between the two strategies, this study suggested that pre-SRS embolization may have a negative effect on post-SRS obliteration. Furthermore, the obliteration rates of the SRS only strategy was significantly higher than that of the Em+SRS strategy in the ruptured cohort, while no such phenomenon was found in the unruptured cohort.
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Affiliation(s)
- Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Hengwei Jin
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translation Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Gao
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Youxiang Li
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translation Medicine for Cerebrovascular Disease, Beijing, China
| | - Shibin Sun
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Ali Liu
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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33
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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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34
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Koch MJ, Bram R, Amin-Hanjani S. Commentary: Does Variceal Drainage Affect Arteriovenous Malformation Obliteration and Hemorrhage Rates After Stereotactic Radiosurgery? A Case-Matched Analysis. Neurosurgery 2021; 89:E219-E220. [PMID: 34318880 DOI: 10.1093/neuros/nyab281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew J Koch
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Richard Bram
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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35
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Catapano JS, Frisoli FA, Nguyen CL, Labib MA, Cole TS, Baranoski JF, Kim H, Spetzler RF, Lawton MT. Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system. J Neurosurg 2021; 136:125-133. [PMID: 34171830 DOI: 10.3171/2020.11.jns203298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Supplemented Spetzler-Martin grading (Supp-SM), which is the combination of Spetzler-Martin and Lawton-Young grades, was validated as being more accurate than stand-alone Spetzler-Martin grading, but an operability cutoff was not established. In this study, the authors surgically treated intermediate-grade AVMs to provide prognostic factors for neurological outcomes and to define AVMs at the boundary of operability. METHODS Surgically treated Supp-SM intermediate-grade (5, 6, and 7) AVMs were analyzed from 2011 to 2018 at two medical centers. Worsened neurological outcomes were defined as increased modified Rankin Scale (mRS) scores on postoperative examinations. A second analysis of 2000-2011 data for Supp-SM grade 6 and 7 AVMs was performed to determine the subtypes with improved or unchanged outcomes. Patients were separated into three groups based on nidus size (S1: < 3 cm, S2: 3-6 cm, S3: > 6 cm) and age (A1: < 20 years, A2: 20-40 years, A3: > 40 years), followed by any combination of the combined supplemented grade: low risk (S1A1, S1A2, S2A1), intermediate risk (S2A2, S1A3, S3A1, or high risk (S3A3, S3A2, S2A3). RESULTS Two hundred forty-six patients had intermediate Supp-SM grade AVMs. Of these patients, 102 had Supp-SM grade 5 (41.5%), 99 had Supp-SM grade 6 (40.2%), and 45 had Supp-SM grade 7 (18.3%). Significant differences in the proportions of patients with worse mRS scores at follow-up were found between the groups, with 24.5% (25/102) of patients in Supp-SM grade 5, 29.3% (29/99) in Supp-SM grade 6, and 57.8% (26/45) in Supp-SM grade 7 (p < 0.001). Patients with Supp-SM grade 7 AVMs had significantly increased odds of worse postoperative mRS scores (p < 0.001; OR 3.7, 95% CI 1.9-7.3). In the expanded cohort of 349 Supp-SM grade 6 AVM patients, a significantly higher proportion of older patients with larger Supp-SM grade 6 AVMs (grade 6+, 38.6%) had neurological deterioration than the others with Supp-SM grade 6 AVMs (22.9%, p = 0.02). Conversely, in an expanded cohort of 197 Supp-SM grade 7 AVM patients, a significantly lower proportion of younger patients with smaller Supp-SM grade 7 AVMs (grade 7-, 19%) had neurological deterioration than the others with Supp-SM grade 7 AVMs (44.9%, p = 0.01). CONCLUSIONS Patients with Supp-SM grade 7 AVMs are at increased risk of worse postoperative neurological outcomes, making Supp-SM grade 6 an appropriate operability cutoff. However, young patients with small niduses in the low-risk Supp-SM grade 7 group (grade 7-) have favorable postoperative outcomes. Outcomes in Supp-SM grade 7 patients did not improve with surgeon experience, indicating that the operability boundary is a hard limit reflecting the complexity of high-grade AVMs.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Fabio A Frisoli
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Candice L Nguyen
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Tyler S Cole
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Jacob F Baranoski
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Helen Kim
- 2Center for Cerebrovascular Research Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
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36
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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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Ai X, Xu J. The predictors of clinical outcomes in brainstem arteriovenous malformations after stereotactic radiosurgery. Medicine (Baltimore) 2021; 100:e26203. [PMID: 34087891 PMCID: PMC8183693 DOI: 10.1097/md.0000000000026203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
The brainstem arteriovenous malformations (BS-AVMs) have a high morbidity and mortality and stereotactic radiosurgery (SRS) has been widely used to treat BS-AVMs. However, no consensus is reached in the explicit predictors of obliteration for BS-AVMs after SRS.To identify the predictors of clinical outcomes for BS-AVMs treated by SRS, we performed a retrospective observational study of BS-AVMs patients treated by SRS at our institution from 2006 to 2016. The primary outcomes were obliteration of nidus and favorable outcomes (AVM nidus obliteration with mRS score ≤2). For getting the outcomes more accurate, we also pooled the results of previous studies as well as our study by meta-analysis.A total of 26 patients diagnosed with BS-AVMs, with mean volume of 2.6 ml, were treated with SRS. Hemorrhage presentation accounted for 69% of these patients. Overall obliteration rate was 42% with mean follow-up of more than five years and two patients (8%) had a post-SRS hemorrhage. Favorable outcomes were observed in 8 patients (31%). Higher margin dose (>15Gy) was associated with higher obliteration (P = .042) and small volume of nidus was associated with favorable outcomes (P = .036). After pooling the results of 7 studies and present study, non-prior embolization (P = .049) and higher margin dose (P = .04) were associated with higher obliteration rate, in addition, the lower Virginia Radiosurgery AVM Scale (VRAS) was associated with favorable outcomes (P = .02) of BS-AVMs after SRS.In the BS-AVMs patients treated by SRS, higher margin dose (19-24Gy) and non-prior embolization were the independent predictors of higher obliteration rate. In addition, smaller volume of nidus and lower VRAS were the potential predictors of long-term favorable outcomes for these patients.
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Affiliation(s)
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Punyawai P, Radomsutthikul N, Dhanachai M, Kobkitsuksakul C, Hansasuta A. Long-term outcomes of 170 brain arteriovenous malformations treated by frameless image-guided robotic stereotactic radiosurgery: Ramathibodi hospital experience. Medicine (Baltimore) 2021; 100:e25752. [PMID: 34106604 PMCID: PMC8133224 DOI: 10.1097/md.0000000000025752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 04/08/2021] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients' demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community.
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Affiliation(s)
- Pritsana Punyawai
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan
| | | | - Mantana Dhanachai
- Department of Diagnostic and Therapeutic Radiology, Division of Radiation Oncology
| | - Chai Kobkitsuksakul
- Department of Diagnostic and Therapeutic Radiology, Division of Interventional Neuroradiology
| | - Ake Hansasuta
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Steinberg JA, Brandel MG, Kang KM, Rennert RC, Pannell JS, Olson SE, Gonda DD, Khalessi AA, Levy ML. Arteriovenous malformation surgery in children: the Rady Children's Hospital experience (2002-2019). Childs Nerv Syst 2021; 37:1267-1277. [PMID: 33404725 DOI: 10.1007/s00381-020-04994-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Compared to adult AVMs, there is a paucity of data on the microsurgical treatment of pediatric AVMs. We report our institutional experience with pediatric AVMs treated by microsurgical resection with or without endovascular embolization and radiation therapy. METHODS We retrospectively reviewed all patients ≤ 18 years of age with cerebral AVMs that underwent microsurgical resection at Rady Children's Hospital 2002-2019. RESULTS Eighty-nine patients met inclusion criteria. The mean age was 10.3 ± 5.0 years, and 56% of patients were male. In total, 72 (81%) patients presented with rupture. Patients with unruptured AVMs presented with headache (n = 5, 29.4%), seizure (n = 9, 52.9%), or incidental finding (n = 3, 17.7%). The mean presenting mRS was 2.8 ± 1.8. AVM location was lobar in 78%, cerebellar/brainstem in 15%, and deep supratentorial in 8%. Spetzler-Martin grade was I in 28%, II in 45%, III in 20%, IV in 6%, and V in 1%. Preoperative embolization was utilized in 38% of patients and more frequently in unruptured than ruptured AVMs (62% vs. 32%, p = 0.022). Radiographic obliteration was achieved in 76/89 (85.4%) patients. Complications occurred in 7 (8%) patients. Annualized rates of delayed rebleeding and recurrence were 1.2% and 0.9%, respectively. The mean follow-up was 2.8 ± 3.1 years. A good neurological outcome (mRS score ≤ 2) was obtained in 80.9% of patients at last follow-up and was improved relative to presentation for 75% of patients. CONCLUSIONS Our case series demonstrates high rates of radiographic obliteration and relatively low incidence of neurologic complications of treatment or AVM recurrence.
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Affiliation(s)
- Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - David D Gonda
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA. .,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
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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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Shinya Y, Hasegawa H, Shin M, Kawashima M, Sugiyama T, Ishikawa O, Koizumi S, Suzuki Y, Nakatomi H, Saito N. Rotational Angiography-Based Gamma Knife Radiosurgery for Brain Arteriovenous Malformations: Preliminary Therapeutic Outcomes of the Novel Method. Neurosurgery 2021; 89:60-69. [PMID: 33770182 DOI: 10.1093/neuros/nyab066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High-definition vascular imaging is desirable for treatment planning in Gamma Knife radiosurgery (GKRS; Elekta AB) for brain arteriovenous malformations (BAVMs). Currently, rotational angiography (RA) provides the clearest 3-dimensional visualization of niduses with high spatial resolution; however, its efficacy for GKRS has not been clarified. At our institution, RA has been integrated into GKRS (RA-GKRS) for better treatment planning and outcomes since 2015. OBJECTIVE To evaluate RA-GKRS outcomes of BAVMs and compare them with conventional GKRS (c-GKRS) outcomes. METHODS We retrospectively analyzed the radiosurgical outcomes of 50 BAVMs treated with RA-GKRS compared with the 306 BAVMs treated with c-GKRS. Considering possible differences in the baseline characteristics, we also created propensity score-matched cohorts and compared the radiosurgical outcomes between them to ensure comparability. RESULTS The obliteration time was shorter in the RA-GKRS group (cumulative rate, 88% vs 65% at 4 yr [P = .001]). Multivariate Cox proportional hazards analysis demonstrated that the RA-GKRS group (hazard ratio 2.38, 95% CI 1.58-3.60; P = .001) had a better obliteration rate. The cumulative 4-yr post-GKRS hemorrhage rates were 4.0% and 2.6% in the RA-GKRS and c-GKRS groups, respectively (P = .558). There was a trend toward early post-GKRS signal change in the RA-GKRS group compared with the c-GKRS group (cumulative rate, 38% vs 29% at 2 yr; P = .118). Those results were also confirmed in the matched cohort analyses. CONCLUSION The integration of RA into GKRS is promising and may provide earlier nidus obliteration.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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42
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Zhu S, Brodin NP, Garg MK, LaSala PA, Tomé WA. Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lehrer EJ, Prabhu AV, Sindhu KK, Lazarev S, Ruiz-Garcia H, Peterson JL, Beltran C, Furutani K, Schlesinger D, Sheehan JP, Trifiletti DM. Proton and Heavy Particle Intracranial Radiosurgery. Biomedicines 2021; 9:31. [PMID: 33401613 PMCID: PMC7823941 DOI: 10.3390/biomedicines9010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Arpan V. Prabhu
- Department of Radiation Oncology, UAMS Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Jennifer L. Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Keith Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
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Rutledge C, Cooke DL, Hetts SW, Abla AA. Brain arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:171-178. [PMID: 33272394 DOI: 10.1016/b978-0-444-64034-5.00020-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Brain arteriovenous malformations are an important cause of intracerebral hemorrhage in the young. Ruptured AVM's are often treated, as the risk of rebleeding is high. The treatment of incidentally discovered, unruptured AVMs is controversial as the morbidity and mortality of treatment may exceed that of the AVM's natural history. Management is multimodal and includes observation with follow up, as well as microsurgical resection, endovascular embolization, and stereotactic radiosurgery. Multidisciplinary teams are important in evaluating patients for treatment. The goal of treatment is complete AVM obliteration while preserving neurologic function.
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Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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45
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Brain Arteriovenous Malformations Classifications: A Surgical Point of View. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 132:101-106. [PMID: 33973036 DOI: 10.1007/978-3-030-63453-7_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Brain arteriovenous malformations (AVMs) classification has been the subject of extensive discussion. The aim of our work was to review the main classification schemes proposed in the literature, which can be summarized in four main groups: (a) traditional schemes oriented to evaluate the operability of AVMs have been joined by (b) specific classifications that evaluate the outcome and the predictability of obliteration of other treatment modalities and (c) others that evaluate the outcome of intracerebral hemorrhages in ruptured AVMs. Eventually, (d) topographical classifications that categorize the subtypes of AVMs located in specific anatomical regions have been drawn. For each classification, we discuss the implications on surgical management.
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Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
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Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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47
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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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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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Chye CL, Wang KW, Chen HJ, Yeh SA, Tang JT, Liang CL. Haemorrhage rates of ruptured and unruptured brain arteriovenous malformation after radiosurgery: a nationwide population-based cohort study. BMJ Open 2020; 10:e036606. [PMID: 33051231 PMCID: PMC7554462 DOI: 10.1136/bmjopen-2019-036606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES The present nationwide population-based cohort study aims to assess the effectiveness of gamma knife radiosurgery (GKS) on ruptured and unruptured brain arteriovenous malformations (AVMs) by evaluating the haemorrhage rates. DESIGN A nationwide, retrospective cohort study. SETTING Taiwan National Health Insurance Research Database (NHIRD). PARTICIPANTS An observational study of 1515 patients who were diagnosed with brain AVMs between 1997 and 2013 from the Taiwan NHIRD. PRIMARY OUTCOME AND SECONDARY OUTCOME MEASURES We performed a survival analysis using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to explore the relationship between treatment modalities (GKS vs non-GKS) and haemorrhage, adjusted for age and sex. RESULTS The GKS and non-GKS groups included 317 and 1198 patients, respectively. Patients in the GKS group (mean±SD, 33.08±15.48 years of age) tended to be younger than those in the non-GKS group (37.40±17.62) (p<0.001). The 15-year follow-up revealed that the rate of bleeding risk was lower in the GKS group than in the non-GKRS group (adjusted HR (aHR) 0.61; 95% CI 0.40 to 0.92). The bleeding risk of ruptured AVMs was significantly lower in GKS group than in the non-GKS group (aHR 0.34; 95% CI 0.19 to 0.62). On the other hand, the bleeding risk of unruptured AVMs was higher in the GKS group than in the non-GKS group (aHR 1.95; 95% CI 1.04 to 3.65). In the unruptured AVM group, the incidence of bleeding was significantly higher among patients in the GKS group that were of >40 years of age (aHR 3.21; 95% CI 1.12 to 9.14). CONCLUSIONS GKS is safe and it reduces the risk of haemorrhage in patients with ruptured AVMs. The administration of GKS to patients with unruptured AVMs who are above the age of 40 years old male might increase the risk of haemorrhage.
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Affiliation(s)
- Cien-Leong Chye
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Kuo-Wei Wang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Han-Jung Chen
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Shyh-An Yeh
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Radiation Oncology, E-Da Hospital, Kaohsiung, Taiwan
| | - James Taoqian Tang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Cheng-Loong Liang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
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Chen Y, Li R, Ma L, Meng X, Yan D, Wang H, Ye X, Jin H, Li Y, Gao D, Sun S, Liu A, Wang S, Chen X, Zhao Y. Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience. Stroke Vasc Neurol 2020; 6:65-73. [PMID: 32928999 PMCID: PMC8005895 DOI: 10.1136/svn-2020-000407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/13/2020] [Accepted: 07/29/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities. METHODS The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017. The rupture risk was represented by annualised haemorrhagic rate. Patients were divided into five groups: conservation, microsurgery, embolisation, stereotactic radiosurgery (SRS) and embolisation+SRS. Neurofunctional outcomes were evaluated by the modified Rankin Scale (mRS). Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts. RESULTS All of 61 brainstem AVMs (12 unruptured and 49 ruptured) were followed up for an average of 4.5 years. The natural annualised rupture risk was 7.3%, and the natural annualised reruptured risk in the ruptured cohort was 8.9%. 13 cases were conservative managed and 48 cases underwent intervention (including 6 microsurgery, 12 embolisation, 21 SRS and 9 embolisation+SRS). In the selection of interventional indication, diffuse nidus were often suggested conservative management (p=0.004) and nidus involving the midbrain were more likely to be recommended for intervention (p=0.034). The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management (p<0.001, p=0.036, respectively). In the subgroup analysis, the follow-up mRS scores of different management modalities were similar whether in the rupture cohort (p=0.064) or the unruptured cohort (p=0.391), as well as the haemorrhage-free survival (p=0.145). In the adjusted Bonferroni correction analysis of the ruptured cohort, microsurgery and SRS could significantly improve the obliteration rate compared with conservation (p<0.001, p=0.001, respectively) and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation (p=0.003, p=0.003, respectively). CONCLUSIONS Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts. If intervention is adopted, partial obliteration should be avoided because of the high subsequent rupture risk. TRIAL REGISTRATION NUMBER NCT04136860.
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Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China .,Department of Neurosurgery, Peking University International Hospital, Beijing, China
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