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Dong M, Xiang S, Hong T, Wu C, Yu J, Yang K, Yang W, Li X, Ren J, Jin H, Li Y, Li G, Ye M, Lu J, Zhang H. Artificial intelligence-based automatic nidus segmentation of cerebral arteriovenous malformation on time-of-flight magnetic resonance angiography. Eur J Radiol 2024; 178:111572. [PMID: 39002268 DOI: 10.1016/j.ejrad.2024.111572] [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: 11/27/2023] [Revised: 03/08/2024] [Accepted: 06/12/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE Accurate nidus segmentation and quantification have long been challenging but important tasks in the clinical management of Cerebral Arteriovenous Malformation (CAVM). However, there are still dilemmas in nidus segmentation, such as difficulty defining the demarcation of the nidus, observer-dependent variation and time consumption. The aim of this study isto develop an artificial intelligence model to automatically segment the nidus on Time-Of-Flight Magnetic Resonance Angiography (TOF-MRA) images. METHODS A total of 92patients with CAVM who underwent both TOF-MRA and DSA examinations were enrolled. Two neurosurgeonsmanually segmented the nidusonTOF-MRA images,which were regarded as theground-truth reference. AU-Net-basedAImodelwascreatedfor automatic nidus detectionand segmentationonTOF-MRA images. RESULTS The meannidus volumes of the AI segmentationmodeland the ground truthwere 5.427 ± 4.996 and 4.824 ± 4.567 mL,respectively. The meandifference in the nidus volume between the two groups was0.603 ± 1.514 mL,which wasnot statisticallysignificant (P = 0.693). The DSC,precision and recallofthe testset were 0.754 ± 0.074, 0.713 ± 0.102 and 0.816 ± 0.098, respectively. The linear correlation coefficient of the nidus volume betweenthesetwo groupswas 0.988, p < 0.001. CONCLUSION The performance of the AI segmentationmodel is moderate consistent with that of manual segmentation. This AI model has great potential in clinical settings, such as preoperative planning, treatment efficacy evaluation, riskstratification and follow-up.
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Affiliation(s)
- Mengqi Dong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Sishi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Chunxue Wu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China.
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Kun Yang
- The National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Wanxin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Xiangyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Hailan Jin
- Department of R&D, UnionStrong (Beijing) Technology Co., Ltd., Beijing, China.
| | - Ye Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China.
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute, Beijing, China.
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Yurtluk MD, Bin-Alamer O, Flickinger JC, Hadjipanayis CG, Niranjan A, Lunsford LD. Multistaged Stereotactic Radiosurgery for Complex Large Lobar Arteriovenous Malformations: A Case Series. Neurosurgery 2024:00006123-990000000-01269. [PMID: 38967428 DOI: 10.1227/neu.0000000000003060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/26/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although stereotactic radiosurgery (SRS) has well defined outcomes in the management of smaller-volume arteriovenous malformations (AVM), this report evaluates the outcomes when SRS is used for large-volume (≥10 cc) lobar AVMs. METHODS Between 1990 and 2022, a cohort of 1325 patients underwent Leksell Gamma Knife SRS for brain AVMs. Among these, 40 patients (25 women; median age: 37 years) with large lobar AVMs underwent volume-staged SRS followed by additional SRS procedures if needed (2-5 procedures). The patients presented with diverse AVM locations and Spetzler-Martin Grades. Before SRS, 16 patients underwent a total of 43 embolization procedures. RESULTS Over a median follow-up of 73 months, 20 patients achieved AVM obliteration. The 3, 5, and 10-year obliteration rates were 9.3%, 15.3%, and 53.3%, respectively. During the latency interval between the first SRS procedure and the last follow-up, 11 patients had intracerebral hemorrhages (ICH) and 6 developed new neurological deficits unrelated to ICH. The postoperative hemorrhage risk after the first SRS was 13.8% at 3 years, 16.6% at 5 years, and 36.2% at 10 years. No hemorrhagic event was documented after confirmed obliteration. Compared with the modified Rankin Scale (mRS) scores before SRS, the mRS improved or remained stable in 28 patients. Nine patients died during the observation interval. Five were related to ICH. CONCLUSION These outcomes underscore both the potential effectiveness and the limitations of multistage SRS procedures for complex high-risk large volume AVMs in critical brain lobar locations. Most patients retained either stable or improved long-term mRS scores. During the latency interval from the first SRS until obliteration, achieved after two or more procedures, the risk of hemorrhage and treatment-related complications persists.
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Affiliation(s)
- Mehmet Denizhan Yurtluk
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Alzate JD, Mashiach E, Bernstein K, De Nigris Vasconcellos F, Qu T, Silverman JS, Shapiro M, Nelson PK, Raz E, Riina HA, Kondziolka D. Quantitative Analysis of Parenchymal Effects and Flow of Large Arteriovenous Malformations Managed With Stereotactic Radiosurgery. Neurosurgery 2023; 93:1057-1065. [PMID: 37235978 DOI: 10.1227/neu.0000000000002539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/03/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) of larger arteriovenous malformations (AVM) is associated with an elevated incidence of adverse radiation effects (ARE). To date, volume-response and dose-response models have been used to predict such effects. To understand radiological outcomes and their hemodynamic effects on the regional brain. METHODS A retrospective analysis was conducted at our institution using a prospective registry of patients managed between 2014 and 2020. We included patients with AVM with a nidus larger than 5 cc who received either single-session or volume-staged Gamma Knife radiosurgery. AVM volume changes, volumes of parenchymal response, and obliteration were analyzed and correlated with transit times and diameters of feeding arteries and draining veins. RESULTS Sixteen patients underwent single-session SRS, and 9 patients underwent volume-staged SRS. The average AVM volume was 12.6 cc (5.5-23). The AVM locations were predominantly lobar (80%) and 17 (68%) were in critical locations. The mean margin dose was 17.2 Gy (15-21), and the median V12Gy was 25.5 cc. Fourteen (56%) AVMs had a transit time shorter than 1 second. The median vein-artery ratio (sum diameter of the veins/sum diameter of feeding arteries) was 1.63 (range, 0.60-4.19). Asymptomatic parenchymal effects were detected in 13 (52%) patients and were symptomatic in 4 (16%) patients. The median time to ARE was 12 months (95% CI 7.6-16.4). On univariate analysis, significant predictors of ARE were lower vein-artery ratio ( P = .024), longer transit time ( P = .05), higher mean dose ( P = .028), and higher D95 ( P = .036). CONCLUSION Transit times and vessel diameters are valuable predictors of the subsequent parenchymal response after SRS. A more quantitative understanding of blood flow is critical for predicting the effects on the regional brain after AVM radiosurgery.
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Affiliation(s)
- Juan Diego Alzate
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Elad Mashiach
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | | | - Tanxia Qu
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | - Joshua S Silverman
- Department of Radiation Oncology, NYU Langone Health, New York University, New York , USA
| | - Maksim Shapiro
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Peter K Nelson
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Eytan Raz
- Department of Interventional Neuroradiology, NYU Langone Health, New York University, New York , USA
| | - Howard A Riina
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
| | - Douglas Kondziolka
- Department of Neurological Surgery, NYU Langone Health, New York University, New York , USA
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Jiang H, Tang X, Weng R, Ni W, Li Y, Su J, Yang H, Xiao W, Wu H, Gu Y, Mao Y. Long-term outcome of a tailored embolization strategy with Gamma Knife radiosurgery for high-grade brain arteriovenous malformations: a single-center experience. J Neurosurg 2022:1-8. [PMID: 36585868 DOI: 10.3171/2022.11.jns221363] [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: 06/12/2022] [Accepted: 11/17/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The safety and efficacy of embolization with Gamma Knife radiosurgery (GKRS) for high-grade brain arteriovenous malformations (bAVMs) are uncertain. The purpose of this study was to elucidate the long-term outcome of a tailored embolization strategy with GKRS and identify the independent factors associated with bAVM obliteration. METHODS Between January 2014 and January 2017, a consecutive cohort of 159 patients with high-grade bAVMs who underwent embolization with GKRS was enrolled in this prospective single-center cohort study. All patients received a tailored embolization strategy with GKRS. The primary outcome was defined as bAVM obliteration. Secondary outcomes were neurological function and complications. RESULTS After a mean follow-up of 40.4 months, 5 patients were lost to follow-up. One hundred eighteen of the remaining 154 patients had favorable neurological outcomes with complete bAVM obliteration. A decrease in bAVM nidus size was observed in 36 patients. Five patients developed intracranial hemorrhage during the latency period, and 2 patients died. The Kaplan-Meier analysis showed that the obliteration rate increased each year and reached the peak point at approximately 3 years. The multivariate Cox regression analysis of factors affecting bAVM obliteration revealed that postembolization bAVM volume < 10 cm3 (p = 0.02), supratentorial location (p < 0.01), staged embolization prior to GKRS (p < 0.01), and mean Spetzler-Martin (SM) grade (p < 0.01) were independent factors associated with a high obliteration rate. CONCLUSIONS These data suggested that high-grade bAVMs treated using a tailored embolization strategy with GKRS were associated with a favorable clinical outcome and obliteration rate. Postembolization bAVM volume < 10 cm3, supratentorial location, staged embolization prior to GKRS, and low mean SM grade were associated with a high obliteration rate.
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Affiliation(s)
- Hanqiang Jiang
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Xuqun Tang
- 2Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
| | - Ruiyuan Weng
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Wei Ni
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Yanjiang Li
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Jiabin Su
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Heng Yang
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Weiping Xiao
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Hanfeng Wu
- 2Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
| | - Yuxiang Gu
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Ying Mao
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
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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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