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Correia de Verdier M, Ronne-Engström E, Borota L, Nilsson K, Blomquist E, Wikström J. Magnetic resonance imaging detected radiation-induced changes in patients with proton radiation-treated arteriovenous malformations. Acta Radiol Open 2021; 10:20584601211050886. [PMID: 34888061 PMCID: PMC8649916 DOI: 10.1177/20584601211050886] [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: 08/23/2021] [Accepted: 09/16/2021] [Indexed: 11/20/2022] Open
Abstract
Background Treatment of intracranial arteriovenous malformations (AVMs) includes surgery, radiation therapy, endovascular occlusion, or a combination. Proton radiation therapy enables very focused radiation, minimizing dose to the surrounding brain. Purpose To evaluate the presence of radiation-induced changes on post-treatment MRI in patients with AVMs treated with proton radiation and to compare these with development of symptoms and nidus obliteration. Material and Methods Retrospective review of pre- and post-treatment digital subtraction angiography and MRI and medical records in 30 patients with AVMs treated with proton radiation. Patients were treated with two or five fractions; total radiation dose was 20–35 physical Gy. Vasogenic edema (minimal, perinidal, or severe), contrast enhancement (minimal or annular), cavitation and nidus obliteration (total, partial, or none) were assessed. Results 26 of 30 patients (87%) developed MRI changes. Vasogenic edema was seen in 25 of 30 (83%), abnormal contrast enhancement in 18 of 26 (69%) and cavitation in 5 of 30 (17%). Time from treatment to appearance of MRI changes varied between 5 and 25 months (median 7, mean 10). Seven patients developed new or deteriorating symptoms that required treatment with corticosteroids; all these patients had extensive MRI changes (severe vasogenic edema and annular contrast enhancement). Not all patients with extensive MRI changes developed symptoms. We found no relation between MRI changes and nidus obliteration. Conclusion Radiation-induced MRI changes are seen in a majority of patients after proton radiation treatment of AVMs. Extensive MRI changes are associated with new or deteriorating symptoms.
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Affiliation(s)
| | | | - Ljubisa Borota
- Department of Surgical Sciences, Section of Neuroradiology, Uppsala University, Uppsala, Sweden
| | - Kristina Nilsson
- Department of Immunology, Genetics and Pathology, Section of Oncology, Uppsala University, Uppsala, Sweden
| | - Erik Blomquist
- Department of Immunology, Genetics and Pathology, Section of Oncology, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Section of Neuroradiology, Uppsala University, Uppsala, Sweden
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Gamma Knife Radiosurgery Followed by Flow-Reductive Embolization for Ruptured Arteriovenous Malformation. J Clin Med 2020; 9:jcm9051318. [PMID: 32370235 PMCID: PMC7290943 DOI: 10.3390/jcm9051318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Aggressive treatment to achieve complete obliteration of brain arteriovenous malformation (AVM) is necessary in patients with a recent history of hemorrhage. The major drawback of Gamma knife radiosurgery (GKRS) alone for AVM is risk of bleeding during the latent period until the AVM occludes. At our center, patients who present with ruptured AVMs are frequently offered GKRS followed by embolization. The goal of this study was to compare outcomes of embolization for patients who have previously undergone GKRS for ruptured AVMs. Methods: A database including 150 GKRS for ruptured AVMs between November 2008 and October 2017 was reviewed. The embolized group was selected by including AVMs with post-GKRS embolization. The non-embolized group was defined as AVMs treated by GKRS alone. Outcomes including obliteration rate, incidence of repeat hemorrhage, and delayed cyst formation were compared between two groups. The predictive factors related to AVM obliteration and complications were analyzed. Results: The study consisted of 81 patients in the non-embolized group and 17 patients in the embolized group. Statistically significant differences were detected between the two groups with respect to age, Pollock-Flickinger score, Spetzler-Martin (SM) grade, eloquence of adjacent brain, and presence of aneurysms. The embolized group included more AVMs with larger median nidus volume. The predictive factors for the obliteration of ruptured AVMs were nidus volume, SM grade, Virginia Radiosurgery AVM Scale (VRAS), and Pollock-Flickinger score and for the subsequent hemorrhage were marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score. The obliteration rates and complication rates after GKRS between groups were not significantly different. However, this study demonstrated statistically significant difference in the cumulative incidence of obliteration in AVMs with SM grade III and IV (p = 0.037). Conclusion: Although the current study demonstrated similar results in patients who underwent GKRS with and without embolization, the embolized group included more AVMs with larger nidus volume, higher SM grade, Pollock-Flickinger score, and aneurysm, which have a lower chance of obliteration and a higher probability of repeat hemorrhage. GKRS followed by embolization appears to be a beneficial approach for the treatment of ruptured AVMs that are at risk for obliteration failure and repeat hemorrhage during the latency period after single-session GKRS alone. Further studies involving a larger number of cases and continuous follow-up are necessary to confirm our conclusions.
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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Ravindra VM, Bollo RJ, Eli IM, Griauzde J, Lanpher A, Klein J, Zhu H, Brockmeyer DL, Kestle JRW, Couldwell WT, Scott RM, Smith E. A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 30952115 DOI: 10.3171/2019.2.peds18731] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 02/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits. METHODS The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living. RESULTS Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up. CONCLUSIONS Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.
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Affiliation(s)
- Vijay M Ravindra
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Robert J Bollo
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ilyas M Eli
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Julius Griauzde
- 2Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Arianna Lanpher
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Jennifer Klein
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Huirong Zhu
- 4Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Douglas L Brockmeyer
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - John R W Kestle
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - R Michael Scott
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Edward Smith
- 3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
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Kailaya-Vasan A, Samuthrat T, Walsh DC. Severe adverse radiation effects complicating radiosurgical treatment of brain arteriovenous malformations and the potential benefit of early surgical treatment. J Clin Neurosci 2018; 55:25-31. [PMID: 30029956 DOI: 10.1016/j.jocn.2018.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/06/2018] [Indexed: 10/28/2022]
Abstract
Treatment of brain arteriovenous malformations (AVM) with stereotactic radiosurgery is rarely complicated by severe adverse radiation effects (ARE). The treatment of these sequelae is varied and often ineffectual. We present three cases of brain AVMs treated with SRS, all complicated by severe AREs. All three cases failed to respond to what is currently considered the standard treatment - corticosteroids - and indeed one patient died as a result of the side effects of their extended use. Two cases were successfully treated with surgical excision of the necrotic lesion resulting in immediate clinical improvement. Having considered the experience described in this paper and reviewed the published literature to date we suggest that surgical treatment of AREs should be considered early in the management of this condition should steroid therapy not result in early improvement.
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Affiliation(s)
- Ahilan Kailaya-Vasan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK.
| | - Thiti Samuthrat
- The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Daniel C Walsh
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK; Institute of Psychiatry, King's College London, DeCrespigny Park, London, UK
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Hasegawa H, Hanakita S, Shin M, Kawashima M, Takahashi W, Ishikawa O, Koizumi S, Nakatomi H, Saito N. Comparison of the Long-term Efficacy and Safety of Gamma Knife Radiosurgery for Arteriovenous Malformations in Pediatric and Adult Patients. Neurol Med Chir (Tokyo) 2018; 58:231-239. [PMID: 29769453 PMCID: PMC6002683 DOI: 10.2176/nmc.st.2018-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is debated whether the efficacy and long-term safety of gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs) differs between adult and pediatric patients. We aimed to clarify the long-term outcomes of GKRS in pediatric patients and how they compare to those in adult patients. We collected data for 736 consecutive patients with AVMs treated with GKRS between 1990 and 2014 and divided the patients into pediatric (age < 20 years, n = 144) and adult (age ≥ 20 years, n = 592) cohorts. The mean follow-up period in the pediatric cohort was 130 months. Compared to the adult patients, the pediatric patients were significantly more likely to have a history of hemorrhage (P < 0.001). The actuarial rates of post-GKRS nidus obliteration in the pediatric cohort were 36%, 60%, and 87% at 2, 3, and 6 years, respectively. Nidus obliteration occurred earlier in the pediatric cohort than in the adult cohort (P = 0.015). The actuarial rates of post-GKRS hemorrhage in the pediatric cohort were 0.7%, 2.5%, and 2.5% at 1, 5, and 10 years, respectively. Post-GKRS hemorrhage was marginally less common in the pediatric cohort than in the adult cohort (P = 0.056). Cyst formation/encapsulated hematoma were detected in seven pediatric patients (4.9%) at a median post-GKRS timepoint of 111 months, which was not significantly different from the rate in the adult cohort. Compared to adult patients, pediatric patients experience earlier therapeutic effects from GKRS for AVMs, and this improves long-term outcomes.
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Affiliation(s)
| | | | - Masahiro Shin
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Osamu Ishikawa
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Nobuhito Saito
- Department of Neurosurgery, University of Tokyo Hospital
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Barbaro NM, Quigg M, Ward MM, Chang EF, Broshek DK, Langfitt JT, Yan G, Laxer KD, Cole AJ, Sneed PK, Hess CP, Yu W, Tripathi M, Heck CN, Miller JW, Garcia PA, McEvoy A, Fountain NB, Salanova V, Knowlton RC, Bagić A, Henry T, Kapoor S, McKhann G, Palade AE, Reuber M, Tecoma E. Radiosurgery versus open surgery for mesial temporal lobe epilepsy: The randomized, controlled ROSE trial. Epilepsia 2018; 59:1198-1207. [PMID: 29600809 DOI: 10.1111/epi.14045] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). METHODS This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. RESULTS A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. SIGNIFICANCE These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.
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Affiliation(s)
- Nicholas M Barbaro
- Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
| | - Mark Quigg
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Mariann M Ward
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Edward F Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Donna K Broshek
- Department of Psychiatry, University of Virginia, Charlottesville, VA, USA
| | - John T Langfitt
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Guofen Yan
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Kenneth D Laxer
- Department of Neurology, California Pacific Medical Center, San Francisco, CA, USA
| | - Andrew J Cole
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Penny K Sneed
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher P Hess
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Wei Yu
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Science, New Delhi, India
| | - Christianne N Heck
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
| | - John W Miller
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Paul A Garcia
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Andrew McEvoy
- Department of Clinical and Experimental Epilepsy, University College London, London, UK
| | - Nathan B Fountain
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Robert C Knowlton
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Anto Bagić
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas Henry
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Siddharth Kapoor
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Guy McKhann
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Adriana E Palade
- Department of Neurology, University of Louisville, Louisville, KY, USA
| | - Markus Reuber
- Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Evelyn Tecoma
- Department of Neurology, University of California San Diego, San Diego, CA, USA
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Meneghelli P, Pasqualin A, Zampieri P, Longhi M, Foroni R, Sini A, Tommasi N, Nicolato A. Surgical Management of Adverse Radiation Effects After Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations: A Population-Based Cohort Study. World Neurosurg 2018; 114:e840-e850. [PMID: 29572169 DOI: 10.1016/j.wneu.2018.03.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this study is to report our experience in the surgical treatment of cerebral arteriovenous malformations (cAVMs) related permanent symptomatic adverse radiation effects (PSAREs), to clarify an appropriate surgical management and to identify the risk factors related to their development. METHODS We evaluated 549 patients treated with Gamma Knife radiosurgery (GKRS) for cAVMs with a follow-up of at least 8 years. Univariate and multivariate analyses were used to test different risk factors related to the development of PSARE. We retrospectively reviewed the records of these patients to analyze the clinical outcome. RESULTS Fourteen patients (2.5%) developed PSARE and were submitted to surgery. Higher average treated volume represents a significant risk factors for the development of PSARE (P < 0.05); on the other hand, older age and higher average dose reduce the risk of PSARE (P < 0.05). A favorable clinical outcome was achieved in 13 patients (93%) after surgery; in 1 patient, the unfavorable outcome was due to hemorrhage that occurred months after GKRS. Serial MRI scans following either surgical removal of the nodule or Ommaya reservoir positioning showed progressive reduction of brain edema in all cases. CONCLUSIONS The management of PSARE is controversial, especially for cAVMs treated with SRS. Surgical removal is rarely needed, but-if unavoidable-it can be a valuable option in experienced hands. A careful preoperative planning is always necessary to detect pathologic blood flow through the PSARE.
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Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Piergiuseppe Zampieri
- Section of Neuroradiology, Department of Diagnosis and Pathology, University and City Hospital, Verona, Italy
| | - Michele Longhi
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Roberto Foroni
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Sini
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Nicola Tommasi
- Centro interdipartimentale di documentazione economica, University of Verona, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
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Alattar AA, Carroll K, Hirshman BR, Joshi RS, Sanghvi P, Chen CC. Cystic Formation After Stereotactic Radiosurgery of Brain Metastasis. World Neurosurg 2018; 114:e719-e728. [PMID: 29551723 DOI: 10.1016/j.wneu.2018.03.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/06/2018] [Accepted: 03/09/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limited information is available on the natural history and etiology of cystic formation after stereotactic radiosurgery (SRS) for brain metastases (BM). We aimed to characterize the natural history of cyst formation after SRS of BM and analyze potential risk factors. METHODS We retrospectively reviewed 214 consecutive patients who underwent a total of 1106 SRSs for BM. Demographic, clinical, dosimetric, and magnetic resonance imaging MRI data were reviewed. Statistical analysis was accomplished using Student's t test, and univariate and multivariate logistic regression. RESULTS The median patient age was 61 years (range, 19-91 years), and the median duration of follow-up was 424 days (range, 91-2934 days). Eleven cases of cyst formation (0.9% of 1106 treated lesions) were identified at SRS-treated BM sites among 9 patients (2 patients developed cysts at independent sites). The median interval between first SRS and first evidence of cyst was 218 days. Seven of the 9 patients (78%) sustained progressive cyst expansion and neurologic decline requiring steroid treatment. Four of these 7 patients (57%) experienced continued neurologic decline and needed surgical fenestration. On univariate analysis, receipt of >4 rounds of SRS was the sole variable associated with an increased risk of cyst formation (odds ratio, 16.58; P = 0.001). This association remained robust after adjusting for duration of follow-up (odds ratio, 13.59; P = 0.003). CONCLUSIONS In our experience with 1106 SRS-treated cases of BM, cyst formation was a rare phenomenon. However, 1 in 3 patients who underwent >4 rounds of SRS sustained cyst formation. A high proportion (78%) of SRS-associated cysts progressively expanded and required medical or surgical treatment.
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Affiliation(s)
- Ali A Alattar
- School of Medicine, University of California San Diego, San Diego, California, USA
| | - Kate Carroll
- School of Medicine, University of California San Diego, San Diego, California, USA
| | - Brian R Hirshman
- Division of Neurological Surgery, University of California San Diego, San Diego, California, USA; Computation, Organization, and Society Program, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Rushikesh S Joshi
- School of Medicine, University of California San Diego, San Diego, California, USA
| | - Parag Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Bir SC, Konar SK, Patra DP, Maiti TK, Minagar A, Nanda A. Management of a complex intracranial arteriovenous malformation with gamma knife radiosurgery: A case report with review of literature. J Clin Neurosci 2018; 49:26-31. [DOI: 10.1016/j.jocn.2017.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/23/2017] [Indexed: 11/25/2022]
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Angiographic "Blush" After Stereotactic Radiosurgery Ablation of Residual Arteriovenous Malformation in Pediatric Patient: Case Report and Review of Literature. World Neurosurg 2017; 111:235-239. [PMID: 29288850 DOI: 10.1016/j.wneu.2017.12.109] [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: 11/20/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION While surgical resection remains a primary treatment for accessible arteriovenous malformations (AVMs), stereotactic radiosurgery (SRS) has become thoroughly integrated into the AVM armamentarium; however, delayed sequelae of this treatment have become evident with increased long-term follow-up. To our knowledge, this is the second case of an aberrant local arterial angiographic blush without early venous drainage or an associated lesion following AVM SRS. CASE DESCRIPTION An 8-year-old female presented with a ruptured 4-cm right medial frontal periventricular Spetzler-Martin grade 3 AVM with isolated intraventricular hemorrhage. She underwent subtotal resection followed by SRS. Six years later, diagnostic cerebral angiography demonstrated a prominent arterial-phase filling microvasculature without early venous drainage in the region of the irradiated residual AVM nidus. CONCLUSION Although there is a paucity of information on angiographic blush following AVM SRS, consensus in the literature suggests that without early venous drainage, these lesions appear to pose an insignificant threat to the patient. These angiographic findings may be on a spectrum of delayed cerebrovascular radiation changes, and thus indefinite follow-up may be considered, especially in pediatric patients.
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Delayed cyst formations and/or expanding hematomas developing after Gamma Knife surgery for cerebral arteriovenous malformations. J Clin Neurosci 2016; 33:96-99. [DOI: 10.1016/j.jocn.2016.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/22/2016] [Accepted: 01/26/2016] [Indexed: 11/22/2022]
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Abstract
ABSTRACT:Background:Stereotactically-focused radiosurgery (SRS) for the treatment of arteriovenous malformations (AVM) has been in widespread use for over two decades. Over this timeframe the indications for treatment, standardization of radiation dosage, and the results expected from treatment have been elaborated. Less well known are the long-term complications associated with SRS. We report three patients who had SRS for the treatment of AVM who developed a cyst at the site of treatment as a late complication.Methods:From 201 patients treated by SRS for an AVM, three developed a cyst at the treatment site. Their clinical presentation, the characteristics of the AVMs and the treatment were reviewed, as well as similar cases gleaned from the literature.Results:Three women, aged 28-43 years, had an AVM treated by: craniotomy and clipping of arterial feeders followed by SRS, by craniotomy for resection followed by SRS or by endo vascular embolization and SRS. The patients did well following treatment but two of them developed a symptomatic and the other an asymptomatic cyst at the treatment site 3-19 years later. The symptomatic patients underwent marsupialization of the cyst and the other is under observation.Conclusion:Stereotactic radiosurgery is an established and safe treatment for patients with AVMs. Delayed cyst formation can occur many years after treatment and long term follow-up is indicated in patients whose AVM has been treated with SRS.
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Chiang JY, Lin HL. Life-threatening posterior fossa cyst induced by pseudomeningocele after operation for acoustic neuroma. Surg Neurol Int 2015; 6:S101-3. [PMID: 25883852 PMCID: PMC4392549 DOI: 10.4103/2152-7806.153645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/12/2014] [Indexed: 11/04/2022] Open
Abstract
Background: Pseudomeningocele is the term used to describe fluid accumulation due to the leakage of cerebrospinal fluid into the surrounding soft tissue. It may cause complications such as cosmetic deformities, chronic meningitis, and/or impingement on vital structures resulting in neurological deficits; nevertheless, life-threatening posterior fossa cyst formation is a rare event. Case Description: We report a case of posterior fossa cyst formation induced by pseudomeningocele with brain stem compression leading to coma with pupillary dilation. These symptoms occurred after an operation for left acoustic neuroma. After emergent decompression and dural repair, the patient recovered well without experiencing any further neurological deficits. Conclusion: We discuss the clinical features, possible pathophysiological mechanisms, and treatment options for pseudomeningocele. Although most cases of pseudomeningocele follow a benign course and need only conservative treatment, the potential attendant complications, such as an enlarged cyst, may still have fatal consequences. We believe that it is beneficial to take an aggressive attitude toward this condition and to consider the possibility of surgical interventions more seriously.
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Affiliation(s)
- Jung-Ying Chiang
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan, R.O.C
| | - Hung-Lin Lin
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan, R.O.C. ; Department of Medicine, China Medical University, Taichung, Taiwan, R.O.C
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Pathological characteristics of cyst formation following gamma knife surgery for arteriovenous malformation. Acta Neurochir (Wien) 2015; 157:293-8. [PMID: 25503297 DOI: 10.1007/s00701-014-2298-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The pathological characteristics of cyst development after gamma knife surgery (GKS) for arteriovenous malformation (AVM) were analysed. METHOD Sixteen male and 12 female patients aged 17-67 years (mean 31.3 years) were retrospectively identified among 868 patients who underwent GKS for AVM at our hospital. The pathological characteristics of the reddish nodular lesion and chronic encapsulated expanding haematoma associated with cyst following GKS for AVM were examined. RESULTS Cyst was associated with chronic encapsulated expanding haematoma in 13, and with nodular lesion in 12 patients. The nidus volume at GKS was 0.1-36 ml (median 6.0 ml), and the prescription dose at the nidus margin was 18-25 Gy (median 20 Gy). Cyst formation was detected from 1.1 to 16 years (mean 7.3 years) after GKS. Seven of the 12 patients with nodular lesion underwent surgery. Ten of the 13 patients with expanding haematoma underwent surgical removal of expanding haematoma. Histological examination was possible in 17 cases. Dilated capillary vessels with wall damage such as hyalinisation and fibrinoid necrosis, marked protein exudation and haemorrhage were the most common findings. Brain parenchyma was observed among the dilated vessels in some cases. Structureless necrotic tissue was not evident. CONCLUSIONS The present study suggests that enhanced nodular lesion on magnetic resonance imaging and chronic encapsulated expanding haematoma associated with cyst may have common aetiopathology caused by late radiation effects, mainly consisting of dilated capillary vessels with wall damage. Massive protein exudation from such damaged capillary vessels is important in cyst development.
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Watanabe T, Nagamine H, Ishiuchi S. Progression of cerebellar chronic encapsulated expanding hematoma during late pregnancy after gamma knife radiosurgery for arteriovenous malformation. Surg Neurol Int 2015; 5:S575-9. [PMID: 25593781 PMCID: PMC4287896 DOI: 10.4103/2152-7806.148054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/04/2014] [Indexed: 12/02/2022] Open
Abstract
Background: The etiology and appropriate management strategy of chronic encapsulated expanding hematoma during pregnancy after gamma knife radiosurgery for arteriovenous malformation (AVM) remain unclear. Case Description: A 34-year-old female developed chronic encapsulated expanding hematoma during late pregnancy, after angiographic disappearance of cerebellar AVM following two courses of gamma knife radiosurgery. The present case implicates pregnancy as a potential promoter of growth and enlargement of chronic encapsulated expanding hematoma, which may become life-threatening and require surgical intervention. Conclusion: Immediate surgical management after delivery may be associated with a favorable outcome, so close follow-up management and patient education are very important in women planning pregnancy.
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Affiliation(s)
- Takashi Watanabe
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hideki Nagamine
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
| | - Shogo Ishiuchi
- Department of Neurosurgery, Faculty of Clinical Medicine, University of the Ryukyus, Okinawa, Japan
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Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience. J Neurosurg Pediatr 2015; 15:71-7. [PMID: 25360855 DOI: 10.3171/2014.9.peds146] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0-2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Matsuo T, Kamada K, Izumo T, Hayashi N, Nagata I. Cyst formation after linac-based radiosurgery for arteriovenous malformation: Examination of predictive factors using magnetic resonance imaging. Clin Neurol Neurosurg 2014; 121:10-6. [DOI: 10.1016/j.clineuro.2014.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 02/25/2014] [Accepted: 03/05/2014] [Indexed: 11/25/2022]
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Ohtakara K, Hoshi H. Cerebral cyst formation following stereotactic ablative irradiation for non-nasopharyngeal head and neck malignancies: imaging findings and relevant dosimetric parameters. Br J Radiol 2014; 87:20140071. [PMID: 24766501 DOI: 10.1259/bjr.20140071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To describe the clinical characteristics, imaging findings and relevant dosimetric parameters of cases presenting with cerebral cyst formation (CCF) after single or oligo-fractionated stereotactic radiotherapy (SRT) for non-nasopharyngeal head and neck malignancies (HNMs). METHODS We identified four cases with the follow-up duration of 5.7-9.1 years from SRT. The irradiated sites included the middle ear in one case and the ethmoid sinus in three cases, two of the latter possessed brain invasion. The chronological changes in MR images and the dose-volume histogram of the adjacent brain tissue were evaluated. RESULTS CCF with or without multiple septi presented with a latency of 29-86 months (median, 45.5 months), which was preceded by either non-specific parenchymal enhancement or typical radiation necrosis. In three cases, CCF adjacent to the frontal base resultantly caused mass effect, and two of these three cases required surgical intervention at 38 and 54 months, respectively, after SRT for alleviation of symptoms. The relation of the irradiated brain volumes to the biological equivalent dose based on the linear-quadratic (LQ) and LQ-cubic models was represented as a threshold. CONCLUSION When contemplating SRT for HNM cases, caution should be exercised to the dose-volume relation-ship of the adjacent brain tissue, especially the frontal base, as well as other critical structures, and long-term vigilant follow-up is also mandatory. ADVANCES IN KNOWLEDGE CCF can occur as an unusual consequence of late brain injury with variable but mostly long latency following SRT for non-nasopharyngeal HNMs adjacent to the brain, even superficial parts that were previously irradiated via conventional radiotherapy.
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Affiliation(s)
- K Ohtakara
- Department of Radiology, Gifu University Graduate School of Medicine, Gifu, Japan
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Arumugham SS, Reddy YCJ. Commonly asked questions in the treatment of obsessive-compulsive disorder. Expert Rev Neurother 2013; 14:151-63. [PMID: 24372473 DOI: 10.1586/14737175.2014.874287] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Obsessive-compulsive disorder (OCD) is a common and often a highly disabling condition that was considered untreatable before the 1960s. The advent of serotonin reuptake inhibitors and exposure and response prevention revolutionized the treatment of OCD. Although they are still the first line treatments for OCD, new treatments like augmentation strategies, brain stimulation techniques, psychosurgery, newer forms of psychotherapy (like cognitive therapy, acceptance and commitment therapy) have been added to the armamentarium. With the available treatment strategies, many patients can achieve at least partial remission of symptoms. Nevertheless, the plethora of information gives rise to many questions on their application for practicing clinicians. We provide evidence-based responses to these questions and suggest a broad guideline for treatment of OCD.
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Affiliation(s)
- Shyam Sundar Arumugham
- Department of Psychiatry, Obsessive-Compulsive Disorder (OCD) Clinic, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India-560029
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Franzin A, Snider S, Boari N, Scomazzoni F, Picozzi P, Spatola G, Gagliardi F, Mortini P. Evaluation of prognostic factors as predictor of AVMS obliteration after Gamma Knife radiosurgery. Acta Neurochir (Wien) 2013; 155:619-26. [PMID: 23420116 DOI: 10.1007/s00701-013-1631-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The reported AVMs obliteration rate after Gamma Knife radiosurgery (GKS) ranges from 70 to 94 %. The objective of the present study was to assess prognostic factors predictive for cerebral AVMs obliteration in 127 patients who underwent GKS. METHODS The AVMs were classified according to the Spetzler-Martin classification. Twenty-one cases (16.5 %) were classified as grade I, 46 cases (36.2 %) as grade II, 51 cases (40.1 %) as grade III, and nine cases (7.1 %) as grade IV-V. The AVMs were deeply located in 16.5 % of patients. The peripheral prescription dose ranged from 16 to 30 Gy (mean 22.3 Gy). The AVMs volume ranged from 0.1 to 13 cc (mean 2.7 cc). RESULTS In 72 patients out of the 104 (69.2 %) with a radiological follow-up, MRI showed the AVM obliteration; in 54 cases (60 %) out of the 90 that performed a DSA, a complete AVM obliteration was achieved (average closure time 48.5 months). The volume of the nidus (p = 0.001), the prescription dose (p = 0.004), the 2002 Pollock-Flickinger classification (p = 0.031), and their 2008 revised classification (p = 0.025) were found to be statistically significant in predicting the probability of AVM closure. In the multivariate analysis, only the prescription dose was found to be an independent prognostic factor (p = 0.009) for AVM obliteration. CONCLUSIONS The volume of the nidus and the prescription dose significantly influence the outcome of radiosurgical treatment. The Pollock-Flickinger classification was found to be a reliable scoring system in predicting the AVM closure and an important tool for selection of patients candidate for GKS.
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Le Feuvre DEJ, Parkes JD, Mukheiber P, James R, Taylor AG. A late haemorrhagic complication in an arteriovenous malformation cured with radiosurgery. Case report. Interv Neuroradiol 2012; 18:149-52. [PMID: 22681728 DOI: 10.1177/159101991201800204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 02/12/2012] [Indexed: 11/17/2022] Open
Abstract
Radiosurgery is a recognized safe form of treating and usually curing arteriovenous malformations (AVMs). Complications related to radiosurgery, especially late sequelae, are rare. Such sequelae may be secondary to incomplete treatment of the original lesion such as haemorrhage, or secondary to the radiation damage to the tissue, or both. Sometimes treatment may induce new lesions. We report a patient who had an AVM cured with radiosurgery, but developed hemisensory loss acutely and had changes on MRI in keeping with a haematoma. We discuss the possible differential diagnosis that should be considered.
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Affiliation(s)
- D E J Le Feuvre
- Division of Neurosurgery, Groote Schuur Hospital, Cape Town, South Africa.
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Surgical and radiosurgical results of the treatment of cerebral arteriovenous malformations. J Clin Neurosci 2012; 19:1001-4. [PMID: 22608804 DOI: 10.1016/j.jocn.2012.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 01/01/2012] [Indexed: 11/23/2022]
Abstract
Microsurgical resection of a cerebral arteriovenous malformation (AVM) allows for an immediate therapeutic cure. Stereotactic radiosurgery (SRS) is a reasonable alternative for inoperable or high-risk lesions requiring treatment. Few series evaluate overall results that include data from both modalities as they more often focus on their treatment method of choice. In this study, we evaluated our AVM database of 129 patients seen over the past eight years at our institution: 73 were treated with microsurgery (57%) while 37 (29%) were treated with SRS. We reviewed angiographic obliteration rates, complication rates, and outcome data, excluding seven patients treated with SRS as they did not have at least two years of angiographic follow-up. Patients undergoing microsurgery had smaller AVM (mean 2.2 cm compared to 3.5 cm for SRS), a smaller proportion of eloquent AVM (53% compared to 83% for SRS), a greater proportion of AVM with superficial drainage only (75% compared to 40% for SRS), and more grade 1 and 2 AVM (78% compared to 17% for SRS). The overall obliteration rate was 80%: 92% for microsurgery and 50% for SRS. The latter increased to 92% for AVM <3 cm, but the obliteration rate was 18% for those AVM >3 cm. Transient complications, including post-SRS hemorrhage, were seen in 11% of patients overall (8% after microsurgery, 17% after SRS). At follow-up, 53% of patients had improved, 37% remained the same, 7% had become worse and 3% had died. As a result of post-SRS hemorrhage, a greater proportion of patients was worse or had died after SRS (20%) compared to those who had been treated with microsurgery (5%).
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KAWAMURA T, ONISHI H, KOHDA Y, HIROSE G. Serious Adverse Effects of Gamma Knife Radiosurgery for Mesial Temporal Lobe Epilepsy. Neurol Med Chir (Tokyo) 2012; 52:892-8. [DOI: 10.2176/nmc.52.892] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Murakami K, Jokura H, Kawagishi J, Watanabe M, Tominaga T. Development of intratumoral cyst or extratumoral arachnoid cyst in intracranial schwannomas following gamma knife radiosurgery. Acta Neurochir (Wien) 2011; 153:1201-9. [PMID: 21369949 DOI: 10.1007/s00701-011-0972-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 02/09/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE Intracranial schwannomas presenting with cyst formation following gamma knife radiosurgery (GKRS) were investigated to clarify their clinicopathological characteristics. METHODS Between 1994 and 2006, 492 patients presenting with intracranial schwannomas underwent GKRS. Among them, seven cases demonstrated either new formation of cysts or enlargement of preexisting cysts, which were treated with microsurgical intervention. These cases were retrospectively reviewed with regard to neuroradiological findings and histopathology. RESULTS These seven cases included five vestibular and two trigeminal schwannomas. Preexisting cysts were enlarged following GKRS in three cases, while they were newly formed in four cases. Salvage microsurgery was carried out at 7-167 months after the GKRS, and subtotal resection was achieved in three, partial resection with or without cyst fenestration in four. Neurological symptoms were improved in all six symptomatic cases. Preoperative MRI demonstrated two characteristic types of cyst. One was the intratumoral type, indicating hemorrhagic change on the MRI. Histopathological analysis demonstrated a cavernous angioma within the solid compartment of tumor. These two cases demonstrated enlargement of residual tumor with new cyst formation after resection of only the cyst. The other type was extratumoral cyst, which had a structure with a thin cyst wall without contrast enhancement, and the cyst was composed of arachnoid cells without tumor cells. Extratumoral cysts enlarged despite effective control of the tumor itself, which may be caused by osmotic gradient induced by tumor degeneration following GKRS. CONCLUSIONS There were two types of cysts, intratumoral cyst and extratumoral arachnoid cyst, which developed following GKRS in intracranial schwannomas. Resection of the solid compartment as well as the cyst is required in schwannomas with expanding intratumoral cyst. Conversely, fenestration of the cyst alone might be effective in extratumoral arachnoid cysts.
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Affiliation(s)
- Kensuke Murakami
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
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Shuto T, Matsunaga S, Suenaga J. Surgical treatment for late complications following gamma knife surgery for arteriovenous malformations. Stereotact Funct Neurosurg 2011; 89:96-102. [PMID: 21293169 DOI: 10.1159/000323543] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 12/10/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND To establish the surgical indications and strategy for late complications following gamma knife surgery (GKS) for arteriovenous malformations (AVMs). METHODS Ten male and 7 female patients aged 17-52 years (mean 28.0 years) were retrospectively identified among 686 patients who underwent GKS for AVM at our hospital. Ten patients showed cyst formation (group A), 2 patients had expanding hematoma (group B), and 5 patients had both cyst and expanding hematoma (group C). RESULTS The mean nidus volume was 10.1 ml (range 0.1-36 ml), and the mean prescription dose at the nidus margin was 19.9 Gy (range 18-28 Gy). Complete obliteration of the nidus was obtained in 12 patients, partial obliteration in 4, and no change in 1. Cyst formation (group A) was asymptomatic in 5 patients, and symptomatic in 5 patients, manifesting as headache, hemianopia, aphasia, and motor weakness. Expanding hematoma (groups B and C) was associated with surrounding brain edema and was symptomatic in all 7 patients. Cyst opening in 1 patient and placement of an Ommaya reservoir in 2 patients were necessary in group A. Both patients in group B underwent craniotomy. Four of the 5 patients in group C required craniotomy. Another patient in group C was lost to follow-up and the final outcome was unknown. CONCLUSIONS Cyst formation is one of the late complications of GKS for AVM. Some cysts show spontaneous regression but others gradually increase in size and become symptomatic, although relatively large asymptomatic cysts are also known. Predicting the future course of a cyst is difficult. Surgery such as placement of an Ommaya reservoir should be considered for symptomatic cases. Expanding hematoma always increases in size and becomes symptomatic, so removal by craniotomy is necessary. Surrounding brain edema decreases rapidly after surgery and neurological symptoms quickly resolve.
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Affiliation(s)
- Takashi Shuto
- Department of Neurosurgery, Yokohama Rosai Hospital, Yokohama, Japan.
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Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology 2010; 35:317-36. [PMID: 19759530 PMCID: PMC3055421 DOI: 10.1038/npp.2009.128] [Citation(s) in RCA: 268] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Psychiatric neurosurgery, specifically stereotactic ablation, has continued since the 1940s, mainly at a few centers in Europe and the US. Since the late 1990s, the resurgence of interest in this field has been remarkable; reports of both lesion procedures and the newer technique of deep brain stimulation (DBS) have increased rapidly. In early 2009, the US FDA granted limited humanitarian approval for DBS for otherwise intractable obsessive-compulsive disorder (OCD), the first such approval for a psychiatric illness. Several factors explain the emergence of DBS and continued small-scale use of refined lesion procedures. DBS and stereotactic ablation have been successful and widely used for movement disorders. There remains an unmet clinical need: current drug and behavioral treatments offer limited benefit to some seriously ill people. Understandings of the neurocircuitry underlying psychopathology and the response to treatment, while still works in progress, are much enhanced. Here, we review modern lesion procedures and DBS for OCD in the context of neurocircuitry. A key issue is that clinical benefit can be obtained after surgeries targeting different brain structures. This fits well with anatomical models, in which circuits connecting orbitofrontal cortex (OFC), medial prefrontal cortex (mPFC), basal ganglia, and thalamus are central to OCD pathophysiology and treatment response. As in movement disorders, dedicated interdisciplinary teams, here led by psychiatrists, are required to implement these procedures and maintain care for patients so treated. Available data, although limited, support the promise of stereotactic ablation or DBS in carefully selected patients. Benefit in such cases appears not to be confined to obsessions and compulsions, but includes changes in affective state. Caution is imperative, and key issues in long-term management of psychiatric neurosurgery patients deserve focused attention. DBS and contemporary ablation also present different patterns of potential benefits and burdens. Translational research to elucidate how targeting specific nodes in putative OCD circuitry might lead to therapeutic gains is accelerating in tandem with clinical use.
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La Piana R, Klein D, Cortes M, Tampieri D. Speech Reorganization after an AVM Bleed Cured by Embolization. A Case Report and Review of the Literature. Interv Neuroradiol 2009; 15:456-61. [PMID: 20465886 DOI: 10.1177/159101990901500415] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 11/21/2009] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Intracerebral arteriovenous malformations (AVMs) are defined as the direct communication of arteries to abnormal veins without interposing capillaries. Although AVMs can have various clinical presentations due to their dynamic nature, the most common presenting sign is intracerebral hemorrhage. Whenever an AVM is discovered, the therapeutic choice is often not obvious and it is influenced not only by the hemodynamic features of the AVM, but also by considerations of the extent of intervention-related morbidity and mortality. A patient with a left frontal AVM is described. He bled three years after gamma knife radiosurgery and developed aphasia. The complete obliteration of the AVM was later achieved by embolization. Functional compensatory brain reorganization and plasticity is discussed, since our patient presented with a fast recovery from aphasia and unexpected contralateral redistribution of the speech function and with preference for his second spoken language.
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Affiliation(s)
- R La Piana
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University; Montreal, QC, Canada - Unit of Child Neurology and Psychiatry, Niguarda Ca' Granda Hospital; Milan, Italy -
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Elwell V, Koo Ng N, Dhanjal M, Peterson D. Cerebral cyst formation in pregnancy following gamma knife surgery of an underlying arteriovenous malformation. Br J Neurosurg 2009; 22:808-9. [DOI: 10.1080/02688690802199912] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Izawa M, Chernov M, Hayashi M, Nakaya K, Kamikawa S, Kato K, Higa T, Ujiie H, Kasuya H, Kawamata T, Okada Y, Kubo O, Iseki H, Hori T, Takakura K. Management and prognosis of cysts developed on long-term follow-up after Gamma Knife radiosurgery for intracranial arteriovenous malformations. ACTA ACUST UNITED AC 2007; 68:400-6; discussion 406. [PMID: 17905064 DOI: 10.1016/j.surneu.2006.11.051] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 11/21/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delayed cyst formation is a well-recognized complication after radiosurgery for intracranial AVM. The objective of the present study was the evaluation of the different management options for these lesions and the corresponding prognosis of patients. METHODS Between 2000 and 2005, 12 patients with intracranial AVM initially treated by GKR were reevaluated at Tokyo Women's Medical University because of delayed cyst formation in the vicinity of the target area. There were 7 men and 5 women. The mean age of the patients was 31.8 years at the time of GKR and 41.1 years at the time of complication. The average period between treatment and diagnosis of the complication constituted 6.7 years. All AVMs had lobar location and showed complete angiographic obliteration after GKR. RESULTS The most common neurological signs and symptoms at the time of cyst presentation were headache (10 cases) and seizures (4 cases). Two patients were asymptomatic. Three patients underwent surgery soon after the diagnosis of the cyst, whereas initial observation was done in another 9. Among the latter, 5 patients had to be treated surgically thereafter because of persistent or aggravated neurological symptoms associated with radiological cyst expansion. Four other patients, including both asymptomatic ones, are in stable condition without surgery. Follow-up after treatment of the cyst varied from 7 to 60 months (average, 34.3 months). All patients are in good condition. CONCLUSIONS Although delayed formation of cysts after GKR for intracranial AVM should be considered as a complication of the radiosurgical treatment, it has a relatively good prognosis. Observation can be recommended as initial option for compensated and asymptomatic patients.
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Affiliation(s)
- Masahiro Izawa
- Department of Neurosurgery, Neurological Institute, Tokyo Women's Medical University, Tokyo 162-8666, Japan.
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Wolak ML, Murphy EC, Powell SZ. Tumefactive cyst with a vascular blush as a late complication after combined embolization and stereotactic radiosurgery treatments for a cerebral arteriovenous malformation. Acta Neurochir (Wien) 2007; 149:705-12; discussion 712. [PMID: 17486288 DOI: 10.1007/s00701-007-1165-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 04/10/2007] [Indexed: 10/23/2022]
Abstract
Cyst formation is a recognized late complication after stereotactic radiosurgery for cerebral arteriovenous malformations (AVMs). We report on a patient with delayed cyst formation after combined embolization and stereotactic radiosurgery treatments for a cerebral AVM. The true nature of the cyst was complicated by tumefactive magnetic resonance MR imaging characteristics. The tumefactive cyst was associated with an additional imaging finding suggestive of a neoplastic lesion - a 'blush' on conventional angiography.
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Affiliation(s)
- M L Wolak
- Department of Neurosurgery, The Methodist Hospital, Houston, Texas, USA.
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Söderman M, Guo WY, Karlsson B, Pelz DM, Ulfarsson E, Andersson T. Neurovascular radiosurgery. Interv Neuroradiol 2006; 12:189-202. [PMID: 20569572 DOI: 10.1177/159101990601200301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Accepted: 08/15/2006] [Indexed: 11/16/2022] Open
Abstract
SUMMARY This article focuses on the treatment of neurovascular diseases, in particular brain arteriovenous malformations (BAVMs), with radiosurgery. The target group for this review is physicians who manage patients with neurovascular diseases, but are not actively engaged in radiosurgery. Radiosurgery for BAVMs is an established treatment with clearly defined risks and benefits. The efficacy of radiosurgery for dural arteriovenous shunts (DAVSs) is probably similar but the treatment has not yet gained the same acceptance. Radiosurgical treatment of cavernomas (cavernous hemangiomas) remains controversial. Well founded predictive models for BAVM radiosurgery show: * The probability of obliteration depends on the dose of radiation given to the periphery of the BAVM. * The risk of adverse radiation effects depends on the total dose of radiation, i.e. the amount of energy imparted into the tissue. The risk is greater in centrally located lesions. The risk of damage to brainstem nucleii and cranial nerves must be added to the risk predicted from current outcome models. * The risk of hemorrhage during the time span before obliteration depends on the BAVM volume, the dose of radiation to the periphery of the lesion and the age of the patient. Central location is a probably also a risk factor.
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Affiliation(s)
- M Söderman
- Dept of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden -
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Shah H, Garg A, Mishra N, Kale S, Gaikwad S. Delayed Symptomatic Cyst Formation following Gamma-Knife Radiosurgery. Neuroradiol J 2006; 19:727-30. [DOI: 10.1177/197140090601900607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 12/05/2006] [Indexed: 11/16/2022] Open
Abstract
We report a case of symptomatic cyst formation as a delayed complication of gamma knife radiosurgery for treatment of intracranial arteriovenous malformation. The cyst was discovered six years after GKS. Initially it was asymptomatic, presenting with symptoms of mass effect after another six months. It was decompressed by a cystoperitoneal shunt following which the symptoms were relieved.
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Affiliation(s)
- H. Shah
- Department Neuroradiology, All India Institute of Medical Sciences; New Delhi, India
| | - A. Garg
- Department Neuroradiology, All India Institute of Medical Sciences; New Delhi, India
| | - N.K. Mishra
- Department Neuroradiology, All India Institute of Medical Sciences; New Delhi, India
| | - S.S. Kale
- Department Neuroradiology, All India Institute of Medical Sciences; New Delhi, India
| | - S.B. Gaikwad
- Department Neuroradiology, All India Institute of Medical Sciences; New Delhi, India
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