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Fernandez LG, Oyon DE, Gibson WS, Mazumdar A, Khan OH. Awake Craniotomy for a Ruptured Arteriovenous Malformation With Preoperative Navigated Transcranial Magnetic Stimulation for Language Mapping: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:109-110. [PMID: 37811921 DOI: 10.1227/ons.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/17/2023] [Indexed: 10/10/2023] Open
Affiliation(s)
- Luis Guillermo Fernandez
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago , Illinois , USA
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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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Shinya Y, Hasegawa H, Kawashima M, Koizumi S, Katano A, Umekawa M, Saito N. Prognosis of Rotational Angiography-Based Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Retrospective Analysis. Neurosurgery 2023; 92:167-178. [PMID: 36255184 DOI: 10.1227/neu.0000000000002168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cerebral dural arteriovenous fistulas (DAVFs) are intracranial vascular malformations with fine, abnormal vascular architecture. High-resolution vascular imaging is vital for their visualization. Currently, rotational angiography (RA) provides the finest 3-dimensional visualization of the arteriovenous shunt with high spatial resolution; however, the efficacies of the integration of RA have never been studied in stereotactic radiosurgery (SRS) for DAVFs until now. Since 2015, our institution has integrated RA into SRS (RA-SRS) to provide more conformal planning, thereby decreasing overtreatment and undertreatment. OBJECTIVE To analyze the outcomes of RA-SRS for DAVFs. METHODS We retrospectively analyzed the outcomes of 51 patients with DAVFs and compared those of 20 DAVFs treated with RA-SRS with those of 31 DAVFs treated with conventional SRS (c-SRS). RESULTS The time to obliteration was shorter in the RA-SRS group (median, 15 months vs 26 months [cumulative rate, 77% vs 33% at 2 years, 77% vs 64% at 4 years]; P = .015). Multivariate Cox proportional hazards analysis demonstrated that RA-SRS (hazard ratio 2.39, 95% CI 1.13-5.05; P = .022) and the absence of cortical venous reflux (hazard ratio 2.12, 95% CI 1.06-4.25; P = .034) were significantly associated with obliteration. The cumulative 5-year post-SRS stroke-free survival rates were 95% and 97% in the RA-SRS and c-SRS groups, respectively ( P = .615). Neurological improvement tended to occur earlier in the RA-SRS group than in the c-SRS group (median time to improvement, 5 months vs 20 months, log-rank test; P = .077). CONCLUSION RA-based SRS may facilitate earlier fistula obliteration and may contribute to early neurological improvement.
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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
| | - 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
| | - Motoyuki Umekawa
- 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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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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5
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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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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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The Irradiated Brain Volume Within 12 Gy Is a Predictor for Radiation-Induced Changes After Stereotactic Radiosurgery in Patients With Unruptured Cerebral Arteriovenous Malformations. Int J Radiat Oncol Biol Phys 2021; 111:785-793. [PMID: 34303557 DOI: 10.1016/j.ijrobp.2021.05.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 05/20/2021] [Accepted: 05/28/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Our purpose was to determine whether the coverage of brain parenchyma within the 12 Gy radiosurgical volume (V12) correlates with the development of radiation-induced changes (RICs) in patients with unruptured cerebral arteriovenous malformations (AVM) after undergoing stereotactic radiosurgery (SRS). METHODS AND MATERIALS This study conducted regular follow-up examinations of 165 patients with unruptured AVMs who had previously undergone SRS. The RICs identified in T2-weighted magnetic resonance imaging (MRI) scans at any time point in the first 3 years after SRS were labeled "early RICs." The RICs identified in T2-weighted MRI scans at 5-year follow-up brain images were labeled "late RICs." Fully automated segmentation was used to analyze the MRI scans from these patients, whereupon the volume and proportion of brain parenchyma within the V12 was calculated. Logistic regression analysis was used to characterize the factors affecting the incidence of early and late RICs of any grade after SRS. RESULTS The median duration of follow-up was 70 months (range, 36-222). Early RICs were identified in 124 of the 165 patients with the highest grades as followed: grade 1 (103 patients), grade 2 (19 patients), and grade 3 (2 patients). Only 103 patients had more than 5 years follow-up, and late RICs were identified in 70 of 103 patients. Seventeen of 70 patients with late RICs were symptomatic. The median volume and proportion of brain parenchyma within the V12 was 22.4 cm3 (range, 0.6-63.9) and 58.7% (range, 18.4-76.8). Univariate analysis revealed that AVM volume and the brain volume within the V12 were correlated with the incidence of both early and late RICs after SRS. Multivariable analysis revealed that only the brain volume within the V12 was significantly associated with the incidence of early and late RICs after SRS. CONCLUSIONS In patients with unruptured AVM, the volume of brain parenchyma within the V12 was an important factor associated with the incidence of early and late RICs after SRS. Before SRS, meticulous radiosurgical planning to reduce brain parenchyma coverage within the V12 could reduce the risk of complications.
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Tan AP, Yeo TT, Yong HRC, Karlsson B. Dynamic radiation-induced imaging changes more than 20 years following gamma knife surgery. Acta Neurochir (Wien) 2021; 163:1935-1939. [PMID: 33999264 DOI: 10.1007/s00701-021-04865-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
Gamma knife radiosurgery (GKS), a technique which involves delivery of a high dose of radiation to a precisely defined target, has become the predominant treatment option for brain metastases (BM) because of its high effectiveness and relatively minimal toxicity. Herein, we report a case of late-onset radiation-induced edema around an asymptomatic cyst, more than 20 years after salvage GKS, with 27 years of imaging follow-up, allowing the description of the evolutionary trajectory of these relatively rare complications. Our reported case also demonstrated the benign nature of delayed cyst formation (DCF), emphasizing that observation alone is reasonable for asymptomatic patients.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore.
- Singapore Institute for Clinical Sciences (SICS), A*STAR Research Entities (ARES), 30 Medical Dr, Singapore, 117609, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore (NUS), 21 Lower Kent Ridge Road, Singapore, 119077, Singapore.
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
| | - Hsiang Rong Clement Yong
- Department of Diagnostic Imaging, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
| | - Bengt Karlsson
- Division of Neurosurgery, Department of Surgery, National University Hospital, 1E Kent Ridge Rd, Singapore, 119228, Singapore
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Shimizu A, Yamaguchi K, Okada Y, Funatsu T, Ishikawa T, Hayashi M, Tamura N, Horiba A, Kawamata T. Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21181. [PMID: 35855079 PMCID: PMC9245776 DOI: 10.3171/case21181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS. OBSERVATIONS Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients. LESSONS This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.
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Affiliation(s)
- Atsushi Shimizu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Noriko Tamura
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ayako Horiba
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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Predictive Factors of Radiation-Induced Changes Following Single-Session Gamma Knife Radiosurgery for Arteriovenous Malformations. J Clin Med 2021; 10:jcm10102186. [PMID: 34069336 PMCID: PMC8158695 DOI: 10.3390/jcm10102186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 11/16/2022] Open
Abstract
We evaluated for possible predictors of radiation-induced changes (RICs) after gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs). We identified the nidal component within AVMs to analyze the correlation between the volume of brain parenchyma within the 50% isodose line (IDL) and RICs. We retrospectively reviewed patients with AVMs who underwent a single-session of GKRS at our institution between 2007 and 2017 with at least a 2-year minimum follow-up. Follow-up magnetic resonance images were evaluated for newly developed T2 signal changes and the proportions of nidus and intervening parenchyma were quantified. A total of 180 AVM patients (98 males and 82 females) with a median age of 34 years were included in the present study. The overall obliteration rate was 67.8%. The median target volume was 3.65 cc. The median nidus and parenchyma volumes within the 50% IDL were 1.54 cc and 2.41 cc, respectively. RICs were identified in 79 of the 180 patients (43.9%). AVMs associated with previous hemorrhages showed a significant inverse correlation with RICs. In a multivariate analysis, RICs were associated with a higher proportion of brain parenchyma within the 50% IDL (hazard ratio (HR) 169.033; p < 0.001) and inversely correlated with the proportion of nidus volume within the 50% IDL (HR 0.006; p < 0.001). Our study identified that a greater proportion of brain tissue between the nidus within the 50% IDL was significantly correlated with RICs. Nidus angioarchitectural complexity and the absence of a prior hemorrhage were also associated with RICs. The identification of possible predictors of RICs could facilitate radiosurgical planning and treatment decisions as well as the planning of appropriate follow-up after GKRS; this could minimize the risk of RICs, which would be particularly beneficial for the treatment of incidentally found asymptomatic AVMs.
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Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6686167. [PMID: 33954197 PMCID: PMC8060080 DOI: 10.1155/2021/6686167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/01/2021] [Accepted: 04/01/2021] [Indexed: 12/03/2022]
Abstract
Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.
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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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13
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Finitsis S, Bernier V, Buccheit I, Klein O, Bracard S, Zhu F, Gauchotte G, Anxionnat R. Late complications of radiosurgery for cerebral arteriovenous malformations: report of 5 cases of chronic encapsulated intracerebral hematomas and review of the literature. Radiat Oncol 2020; 15:177. [PMID: 32698881 PMCID: PMC7374821 DOI: 10.1186/s13014-020-01616-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/13/2020] [Indexed: 01/04/2023] Open
Abstract
Background Chronic encapsulated intracerebral hematomas (CEIHs) are a rare, late complication of radiosurgery for intracranial AVM. We present 5 cases treated mostly by surgical excision and review the literature. Methods Patients (age 39, 42, 36, 31, 62) presented with headache, paresthesia, hemiparesis or were asymptomatic. CEIHs presented 10 to 13 years (median 12 years) post radiosurgery. Three patients had demonstrated early radiation induced changes post radiosurgery. Angiographic cure, assessed with DSA, was present in all cases except 1 case with a small nidus remnant. MRI demonstrated mixed lesions with a solid enhancing part, organized hematoma and extensive surrounding edema while three cases had also a cystic component. Results Excision of the CEIHs with complete or partial removal of the capsule was performed in 4 patients and resulted in marked clinical improvement. One patient was managed conservatively with administration of steroids as surgery was judged excessively hazardous with eventual stabilization of his symptoms. Conclusions CEIHs are rare, late complications of radiosurgery for cranial AVM. They may be asymptomatic or provoke symptoms and may be preceded by early radiation induced changes. Complete removal of CEIHS is an effective treatment. Because of the long latency period of CEIHs, patients who had radiosurgery for brain AVMs should be followed by MRI at least 10 years even after complete obliteration.
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Affiliation(s)
- Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Kyriakidi 1, 54621, Thessaoniki, Greece.
| | - Valerie Bernier
- Centre Alexis Vautrin, Institut de Cancérologie de Lorraine, 6 avenue de Bourgogne CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Isabelle Buccheit
- Centre Alexis Vautrin, Institut de Cancérologie de Lorraine, 6 avenue de Bourgogne CS 30519, 54519, Vandoeuvre-lès-Nancy Cedex, France
| | - Olivier Klein
- Hôpital d'Enfants, CHU de Nancy - Hôpitaux de Brabois, Rue du Morvan, 54511, Vandoeuvre-lès-Nancy Cedex, France
| | - Serge Bracard
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Universitaire de Nancy, 29 avenue du maréchal de Lattre de Tassigny CO 60034, 54035, Nancy, France
| | - Francois Zhu
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Universitaire de Nancy, 29 avenue du maréchal de Lattre de Tassigny CO 60034, 54035, Nancy, France
| | - Guillaume Gauchotte
- Département de Biopathologie - Anatomie et Cytologie Pathologiques, CHRU de Nancy - CHRU/ICL - bâtiment BBB, Rue du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - René Anxionnat
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Universitaire de Nancy, 29 avenue du maréchal de Lattre de Tassigny CO 60034, 54035, Nancy, France
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Byun J, Kwon DH, Lee DH, Park W, Park JC, Ahn JS. Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM. J Korean Neurosurg Soc 2020; 63:415-426. [PMID: 32423182 PMCID: PMC7365281 DOI: 10.3340/jkns.2020.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/29/2020] [Indexed: 11/27/2022] Open
Abstract
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.
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Affiliation(s)
- Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kosyrkova AV, Goryainov SA, Kravchuk AD, Golanov AV, Maryashev SA, Vetlova ER, Antipina NA, Pronin IN, Batalov AI, Zakharova NE, Potapov AA. [Multicystic transformation of the post-radiation necrosis zone of the brain. A case report and literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2020; 84:72-82. [PMID: 32412196 DOI: 10.17116/neiro20208402172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Post-radiation cyst of the brain is a rare complication that often arises many years after irradiation for head and neck neoplasms. The majority of the articles devoted to this problem are small samples or case reports. Nevertheless, the overall number of these patients is steadily increasing. The feature of post-radiation cysts is gradual enlargement followed by general cerebral and focal symptoms and ineffectiveness of therapy. Some patients with clinically significant post-radiation cysts can require surgical treatment. Insertion of Ommaya reservoir may be preferred in these patients. In some cases, this method is ineffective and more complex surgeries may be required. The objectives of this report were to analyze literature data and describe the patient with multiple recurrent brain cysts after previous irradiation for frontotemporal skin melanoma. Twenty-seven publications were analyzed for the period from 1997 to 2018. According to the literature, the incidence of post-radiation cysts varies from 0.4% to 28%, timing of occurrence - from 2 months to 27 years. These values significantly depend on the underlying disease. We report a 27-year-old patient who admitted to the Burdenko Neurosurgery Center with focal and general cerebral symptoms after irradiation for skin melanoma of the right frontotemporal region. These symptoms were caused by cystic lesion of the right temporal and frontal lobes. Surgical treatment consisted in insertion of 2 Ommaya reservoirs. This approach ensured complete regression of the cyst in the right temporal lobe and mild decrease of the cyst in the right frontal lobe.
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Affiliation(s)
| | | | | | - A V Golanov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - E R Vetlova
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A I Batalov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - A A Potapov
- Burdenko Neurosurgical Center, Moscow, Russia
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16
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Peng SJ, Lee CC, Wu HM, Lin CJ, Shiau CY, Guo WY, Pan DHC, Liu KD, Chung WY, Yang HC. Fully automated tissue segmentation of the prescription isodose region delineated through the Gamma knife plan for cerebral arteriovenous malformation (AVM) using fuzzy C-means (FCM) clustering. NEUROIMAGE-CLINICAL 2018; 21:101608. [PMID: 30497981 PMCID: PMC6413475 DOI: 10.1016/j.nicl.2018.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/31/2018] [Accepted: 11/18/2018] [Indexed: 11/21/2022]
Abstract
Background Gamma knife radiosurgery (GKRS) is a common treatment for cerebral arterio-venous malformations (AVMs), particularly in cases where the malformation is deep-seated, large, or in eloquent areas of the brain. Unfortunately, these procedures can result in radiation injury to brain parenchyma. The fact that every AVM is unique in its vascular morphology makes it nearly impossible to exclude brain parenchyma from isodose radiation exposure during the formulation of a GKRS plan. Calculating the percentages of the various forms of tissue exposed to specific doses of radiation is crucial to understanding the clinical responses and causes of brain parenchyma injury following GKRS for AVM. Methods In this study, we developed a fully automated algorithm using unsupervised classification via fuzzy c-means clustering for the analysis of T2 weighted images used in a Gamma knife plan. This algorithm is able to calculate the percentages of nidus, brain tissue, and cerebrospinal fluid (CSF) within the prescription isodose radiation exposure region. Results The proposed algorithm was used to assess the treatment plan of 25 patients with AVM who had undergone GKRS. The Dice similarity index (SI) was used to determine the degree of agreement between the results obtained using the algorithm and a visually guided manual method (the gold standard) performed by an experienced neurosurgeon. In the nidus, the SI was (74.86 ± 1.30%) (mean ± standard deviation), the sensitivity was (83.05 ± 11.91)%, and the specificity was (86.73 ± 10.31)%. In brain tissue, the SI was (79.50 ± 6.01)%, the sensitivity was (73.05 ± 9.77)%, and the specificity was (85.53 ± 7.13)%. In the CSF, the SI was (69.57 ± 15.26)%, the sensitivity was (89.86 ± 5.87)%, and the specificity was (92.36 ± 4.35)%. Conclusions The proposed clustering algorithm provides precise percentages of the various types of tissue within the prescription isodose region in the T2 weighted images used in the GKRS plan for AVM. Our results shed light on the causes of brain radiation injury after GKRS for AVM. In the future, this system could be used to improve outcomes and avoid complications associated with GKRS treatment. A novel image analytical method for the analysis of images of an AVM in a GKRS plan Fuzzy c-means clustering was used for analyses of T2w images in the GKRS plan. Automatic calculation of percentages of tissue inside the isodose line Brain tissue percentages of the nidus of the AVM predict risk of complication. Proposed method could be used to avoid complications associated after GKRS.
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Affiliation(s)
- Syu-Jyun Peng
- Biomedical Electronics Translational Research Center, National Chiao Tung University, Hsinchu, Taiwan; Institute of Electronics, National Chiao-Tung University, Hsinchu, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Shuang-Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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17
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Russell D, Peck T, Ding D, Chen CJ, Taylor DG, Starke RM, Lee CC, Sheehan JP. Stereotactic radiosurgery alone or combined with embolization for brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg 2018; 128:1338-1348. [DOI: 10.3171/2016.11.jns162382] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.
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Affiliation(s)
| | | | - Dale Ding
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Davis G. Taylor
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- 4Deparment of Neurological Surgery, University of Miami, Florida
| | - Cheng-Chia Lee
- 3Deparment of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Jason P. Sheehan
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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18
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Ye Z, Ai X, You C. Letter to the Editor. Cyst formation after stereotactic radiosurgery for brain AVMs. J Neurosurg 2018; 129:259-262. [PMID: 29676692 DOI: 10.3171/2017.11.jns172776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Pomeraniec IJ, Ding D, Starke RM, Liu KC, Mrachek EK, Lopes MB, Sheehan JP. Delayed cyst formation after stereotactic radiosurgery for brain arteriovenous malformations. J Neurosurg 2017; 129:937-946. [PMID: 29192860 DOI: 10.3171/2017.6.jns17559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is a commonly employed treatment modality for brain arteriovenous malformations (AVMs). However, due to the low frequency of delayed cyst formation after AVM SRS, as well as the prolonged time interval between treatment and its occurrence, the characteristics of post-SRS cyst formation are not well defined. Therefore, the aims of this retrospective cohort study are to determine the rate of cyst formation after SRS for AVMs, identify predictive factors, and evaluate the clinical sequelae of post-SRS cysts. METHODS The authors analyzed an SRS database for AVM patients who underwent SRS at the University of Virginia and identified those who developed post-SRS cysts. Statistical analyses were performed to determine predictors of post-SRS cyst formation and the effect of cyst formation on new or worsening seizures after SRS. RESULTS The study cohort comprised 1159 AVM patients treated with SRS; cyst formation occurred in 17 patients (post-SRS cyst rate of 1.5%). Compared with patients who did not develop post-SRS cysts, those with cyst formation were treated with a greater number of radiosurgical isocenters (mean 3.8 vs 2.8, p = 0.047), had a longer follow-up (mean 132 vs 71 months, p < 0.001), were more likely to develop radiological radiation-induced changes (RIC) (64.7% vs 36.1%, p = 0.021), and had a longer duration of RIC (57 vs 21 months, p < 0.001). A higher number of isocenters (p = 0.014), radiological RIC (p = 0.002), and longer follow-up (p = 0.034) were found to be independent predictors of post-SRS cyst formation in the multivariate analysis. There was a trend toward a significant association between cyst formation and new or worsening seizures in univariate analysis (p = 0.054). CONCLUSIONS Patients with greater nidal complexity appear to be more prone to post-SRS cyst formation. The findings of this study emphasize the importance of long-term follow-up for patients who have undergone AVM SRS, even after nidal obliteration is achieved. Post-SRS cysts may be epileptogenic, although seizure outcomes after AVM SRS are multifactorial.
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Affiliation(s)
| | | | - Robert M Starke
- 5Departments of Neurosurgery and Radiology, Jackson Memorial Hospital and University of Miami Hospital, Miami, Florida
| | | | - E Kelly Mrachek
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
| | - M Beatriz Lopes
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
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20
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Ilyas A, Chen CJ, Ding D, Buell TJ, Raper DMS, Lee CC, Xu Z, Sheehan JP. Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2017; 83:365-376. [DOI: 10.1093/neuros/nyx502] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/11/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Neurosurgery, Barrow Neurologic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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21
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Ilyas A, Chen CJ, Ding D, Mastorakos P, Taylor DG, Pomeraniec IJ, Lee CC, Sheehan J. Cyst formation after stereotactic radiosurgery for brain arteriovenous malformations: a systematic review. J Neurosurg 2017; 128:1354-1363. [PMID: 28548596 DOI: 10.3171/2016.12.jns162478] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs. METHODS A literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data. RESULTS Based on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years). CONCLUSIONS Cyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.
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Affiliation(s)
- Adeel Ilyas
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Dale Ding
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Panagiotis Mastorakos
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Davis G Taylor
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - I Jonathan Pomeraniec
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Cheng-Chia Lee
- 2Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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22
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Pollock BE, Link MJ, Branda ME, Storlie CB. Incidence and Management of Late Adverse Radiation Effects After Arteriovenous Malformation Radiosurgery. Neurosurgery 2017; 81:928-934. [DOI: 10.1093/neuros/nyx010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/13/2016] [Indexed: 11/14/2022] Open
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23
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Nagy G, Grainger A, Hodgson TJ, Rowe JG, Coley SC, Kemeny AA, Radatz MW. Staged-Volume Radiosurgery of Large Arteriovenous Malformations Improves Outcome by Reducing the Rate of Adverse Radiation Effects. Neurosurgery 2017; 80:180-192. [DOI: 10.1227/neu.0000000000001212] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/28/2015] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND: The treatment of large arteriovenous malformations (AVMs) remains challenging. Recently, staged-volume radiosurgery (SVRS) has become an option.
OBJECTIVE: To compare the outcome of SVRS on large AVMs with our historical, single-stage radiosurgery (SSRS) series.
METHODS: We have been prospectively collecting data of patients treated by SVRS since 2007. There were 84 patients who had a median age of 37 years (range, 9-62 years) who were treated until July 2013. The outcomes of 76 of those who had follow-ups available were analyzed and compared with the outcomes of 122 patients treated with the best SSRS technique.
RESULTS: There were 21.5% of AVMs that were deep seated, and 44% presented with hemorrhage resulting in 45% fixed neurological deficit. There were 14% of patients who had undergone embolization before radiosurgery. The median nidus treatment volume was 19.7 cm3 (6.65-68.7) and 17.5 Gy (13-22.5) prescription isodose was given. Of the 44 lesions having radiological follow-up at 4 years, 61.4% were completely obliterated. Previous embolization (50% with and 63% without) and higher Spetzler-Martin grades appeared to be the negative factors in successful obliteration, but treatment volume was not. Within 3 years after radiosurgery, the annual bleed rates of unruptured and previously ruptured AVMs were 3.2% and 5.6%, respectively. Three bleeds were fatal and 2 resulted in significant modified Rankin scale 3 morbidity. These rates differ little from SSRS. Temporary adverse radiation effects (AREs) did not change significantly, but permanent AREs dropped from 15% to 6.5% (P = .03) compared with SSRS.
CONCLUSION: Obliteration and hemorrhage rates of large AVMs treated by SVRS are similar to historical SSRS. However, SVRS offers a lower rate of AREs.
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Affiliation(s)
- Gábor Nagy
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Alison Grainger
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Timothy J. Hodgson
- Department of Radiology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Jeremy G. Rowe
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Stuart C. Coley
- Department of Radiology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - Matthias W.R. Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
- Thornbury Radiosurgery Centre, Sheffield, United Kingdom
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Amponsah K, Ellis TL, Chan MD, Lovato JF, Bourland JD, deGuzman AF, Ekstrand KE, Munley MT, McMullen KP, Shaw EG, Tatter SB. Retrospective analysis of imaging techniques for treatment planning and monitoring of obliteration for gamma knife treatment of cerebral arteriovenous malformation. Neurosurgery 2013; 71:893-9. [PMID: 22791027 DOI: 10.1227/neu.0b013e3182672a83] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It has been well established that Gamma Knife radiosurgery (GKS) is an effective treatment for brain arteriovenous malformations (AVMs). OBJECTIVE To evaluate complete obliteration rates for magnetic resonance imaging (MRI)-based GKS treatment planning performed with and without angiography and to conduct a preliminary assessment of the utility of using pulsed arterial spin labeling (PASL) magnetic resonance (MR) perfusion imaging to confirm complete obliteration. METHODS Forty-six patients were identified who had undergone GKS without embolization with a minimum follow-up of 2 years. One group was planned with integrated stereotactic angiography and MR (spoiled gradient recalled) images obtained on the day of GKS. A second technique avoided the risk of arteriography by using only axial MR images. Beginning in 2007, PASL MR perfusion imaging was routinely performed as a portion of the follow-up MRI to assess the restoration of normal blood flow of the nidus and surrounding area. RESULTS The overall obliteration rate for the angiography/MRI group was 88.0% (29 of 33). Patients in the MRI-only group had an obliteration rate of 61.5% (8 of 13), with P=.092 with the Fisher exact test, which is not statistically significant. A Kaplan-Meier analysis was also not statistically significant (log rank test, P=.474). Four of 9 patients with incomplete obliteration on angiography also had shown residual abnormal blood flow on PASL imaging. CONCLUSION This retrospective analysis shows that treatment planning technique used in GKS does not play a role in the eventual obliteration of treated AVMs. PASL may have potential in the evaluation of AVM obliteration.
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Affiliation(s)
- Kwame Amponsah
- Departments of *Neurosurgery and ‡Radiation Oncology §Division of Public Health Sciences, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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25
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Koga T, Shin M, Terahara A, Saito N. Outcomes of Radiosurgery for Brainstem Arteriovenous Malformations. Neurosurgery 2011; 69:45-51; discussion 51-2. [DOI: 10.1227/neu.0b013e31821421d1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Arteriovenous malformations (AVMs) in the brainstem yield a high risk of hemorrhage. Although stereotactic radiosurgery (SRS) is accepted, because of high surgical morbidity and mortality, outcomes are still unclear.
OBJECTIVE:
We previously reported the early results of SRS for brainstem AVMs. Here, we obtained data from a longer follow-up for a larger number of patients and present precise outcomes based on the latest follow-up data.
METHODS:
Forty-four patients with brainstem AVMs were treated by SRS. Outcomes such as the rates of obliteration, hemorrhage after treatment, and adverse effects were retrospectively analyzed.
RESULTS:
The annual hemorrhage rate before SRS was 17.5%. The mean follow-up period after SRS was 71 months (range, 2-168 months). The actuarial obliteration rate confirmed by angiography was 52% at 5 years. Factors associated with higher obliteration rate were previous hemorrhage (P = .048) and higher margin dose (P = .048). For patients treated with a margin dose of ≥ 18 Gy, the obliteration rate was 71% at 5 years. Persistent worsening of neurological symptoms was observed in 5%. The annual hemorrhage rate after SRS was 2.4%. Four patients died of rebleeding, and disease-specific survival rate was 86% at 10 years after treatment.
CONCLUSION:
Nidus obliteration must be achieved for brainstem AVMs because they possibly cause lethal hemorrhage even after SRS. Treatment with a high margin dose is desirable to obtain favorable outcomes for these lesions. Additional treatment should be considered for an incompletely obliterated nidus.
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Affiliation(s)
- Tomoyuki Koga
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Atsuro Terahara
- Departments of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
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26
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Ishikawa E, Yamamoto M, Saito A, Kujiraoka Y, Iijima T, Akutsu H, Matsumura A. DELAYED CYST FORMATION AFTER GAMMA KNIFE RADIOSURGERY FOR BRAIN METASTASES. Neurosurgery 2009; 65:689-94; discussion 694-5. [PMID: 19834373 DOI: 10.1227/01.neu.0000351771.46273.22] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Gamma knife radiosurgery (GKRS) is occasionally a useful tool for maintaining good brain status in patients with brain metastases (METs). Conversely, we recently experienced patients with delayed cyst formation (DCF) several years after GKRS, a complication not previously reported. Herein we assessed the frequency and characteristics of DCF after GKRS for METs.
METHODS
Eighty of 1209 patients with METs treated with GKRS maintained good brain status for more than 3 years without regrowth of tumorous lesions in the brain. In this study, DCF was defined as secondary cyst formation more than 3 years after the first GKRS in patients with METs who did not have cysts at the start of MET treatment. The 80 patients were divided into 2 groups (DCF group and non-DCF group) for assessment of the frequency and characteristics of DCF. Of the patients with cystic METs at the start of MET treatment, 16 were included in the latter group.
RESULTS
Among these 80 patients, 8 had DCF after GKRS (DCF group), detected by magnetic resonance imaging from 37 to 121 months after the first GKRS (median interval of 53 months). Of these 8 patients, 7 were symptomatic, and surgical treatments including Ommaya reservoir placement were needed in 5. A comparison of the non-DCF and DCF groups revealed that a higher number of GKRS treatments was a risk factor for DCF. Moreover, patients surviving more than 5 years after the initial GKRS are at risk for DCF.
CONCLUSION
Although DCF is not a widely recognized complication of GKRS for METs, we advocate careful follow-up, with surgical intervention for DCF if necessary, for frequently irradiated and long-surviving patients with METs treated with GKRS.
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Affiliation(s)
- Eiichi Ishikawa
- Department of Neurosurgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | | | - Atsushi Saito
- Department of Neurosurgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Yuji Kujiraoka
- Department of Neurosurgery, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Tatsuo Iijima
- Department of Pathology, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
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Kasliwal MK, Kale SS, Gupta A, Kiran NAS, Sharma MS, Sharma BS, Mahapatra AK. Outcome after hemorrhage following Gamma Knife surgery for cerebral arteriovenous malformations. J Neurosurg 2009; 110:1003-9. [DOI: 10.3171/2008.10.17675] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs).
Methods
Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen.
Results
The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS.
Conclusions
The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.
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28
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Combined management of intracranial arteriovenous malformations with embolization and Gamma Knife radiosurgery: comparative evaluation of the long-term results. ACTA ACUST UNITED AC 2009; 71:43-52; discussion 52-3. [DOI: 10.1016/j.surneu.2007.11.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 11/27/2007] [Indexed: 11/15/2022]
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29
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Choe JG, Im YS, Kim JS, Hong SC, Shin HJ, Lee JI. Retrospective analysis on 76 cases of cerebral arteriovenous malformations treated by gamma knife radiosurgery. J Korean Neurosurg Soc 2008; 43:265-9. [PMID: 19096630 DOI: 10.3340/jkns.2008.43.6.265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Accepted: 06/13/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Outcome of gamma knife radiosurgery (GKS) in the consecutive 100 cases with cerebral arteriovenous malformations (AVMs) was analyzed. METHODS Data from initial 100 patients treated with GKS in the authors' institute were reviewed retrospectively. Spetzler-Martin grade at diagnosis were I in 18 patients, II in 27, III in 36, IV in 11, and V in 8. Thirty-five patients had experienced previous bleeding, 27 patients presented with seizure, and 31 patients presented with headache. The mean volume of the lesion was 4.3 cm(3) (0.1-29.3 cm(3)). The median radiation dose delivered to the margin was 20.0 Gy (13-32 Gy). Mean follow-up period was 37.5 months (5-63 months). RESULTS Angiographic follow-up was performed in 48 patients at least 2 years after GKS. Sixteen patients were lost in follow up following 2 years from GKS. Twenty-eight of 48 patients (58%) showed complete obliteration and 20 patients (42%) showed partial obliteration. Seven patients presented with post-GKS hemorrhage. Adverse radiation effect (ARE) was observed at follow-up MRI in 25 of 76 patients, and it was symptomatic in 5 patients. Complete obliteration was confirmed in 24 of 31 (77%) patients with volume less than 4 cm(3), meanwhile only 4 of 17 (24%) patients with volume of 4 cm(3) or more showed complete obliteration. Complete obliteration rate was 67% with 20 Gy or higher marginal dose, 63% with 15-20 Gy, and 17% with less than 15 Gy. CONCLUSION GKS can provide high rates of obliteration with acceptable risk of morbidity in a subgroup of small AVMs. However, overall outcome in whole spectrum of AVMs, in which large proportion of cases have unfavorable characteristics for radiosurgery, is much worse. More effective therapeutic strategy needs to be developed for large AVMs that are difficult to be managed with current available treatment modalities.
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Affiliation(s)
- Jae-Gyun Choe
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul Korea
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30
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Back AG, Vollmer D, Zeck O, Shkedy C, Shedden PM. Retrospective analysis of unstaged and staged Gamma Knife surgery with and without preceding embolization for the treatment of arteriovenous malformations. J Neurosurg 2008; 109 Suppl:57-64. [DOI: 10.3171/jns/2008/109/12/s10] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors conducted a retrospective study to examine data on rates of obliteration of arteriovenous malformations (AVMs) with use of various combinations of treatment modalities based on Gamma Knife surgery (GKS). The authors believe that this study is the first to report on patients treated with embolization followed by staged GKS.
Methods
The authors identified 150 patients who underwent GKS for treatment of AVMs between 1994 and 2004. In a retrospective study, 4 independent groups emerged based on the various combinations of treatment: 92 patients who underwent unstaged GKS, 28 patients who underwent embolization followed by unstaged GKS, 23 patients who underwent staged GKS, and 7 patients who underwent embolization followed by staged GKS. A minimum of 3 years of follow-up after the last GKS treatment was required for inclusion in the retrospective analysis. Angiograms, MR images, or CT scans at follow-up were required for calculating rates of obliteration of AVMs.
Results
Fifty-seven of 150 patients (38%) supplied angiograms, and overall obliteration was confirmed in 43 of these 57 patients (75.4%). An additional 37 patients had follow-up MR images or CT scans. The overall obliteration rate, including patients with follow-up angiograms and patients with follow-up MR images or CT scans, was 68 of 94 (72.3%). Patients who underwent unstaged GKS had a follow-up rate of 58.7% (54 of 92) and an obliteration rate of 75.9% (41 of 54). Patients who underwent embolization followed by unstaged GKS had a follow-up rate of 53.5% (15 of 28) and an obliteration rate of 60.0% (9 of 15). Patients who underwent staged GKS had a follow-up rate of 82.6% (19 of 23) and an obliteration rate of 73.7% (14 of 19). Patients who underwent embolization followed by staged GKS had a follow-up rate of 85.7% (6 of 7) and an obliteration rate of 66.7% (4 of 6).
Conclusions
Gamma Knife surgery is an effective means of treating AVMs. Embolization prior to GKS may reduce AVM obliteration rates. Staged GKS is a promising method for obtaining high obliteration rates when treating larger AVMs in eloquent locations.
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Affiliation(s)
- Adam G. Back
- 1Greater Houston Foundation for Medical Research and Education; and
| | | | - Otto Zeck
- 2Memorial Hermann Hospital Gamma Knife, Houston, Texas
| | - Clive Shkedy
- 2Memorial Hermann Hospital Gamma Knife, Houston, Texas
| | - Peter M. Shedden
- 1Greater Houston Foundation for Medical Research and Education; and
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31
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Han JH, Kim DG, Chung HT, Park CK, Paek SH, Kim JE, Jung HW, Han DH. Clinical and neuroimaging outcome of cerebral arteriovenous malformations after Gamma Knife surgery: analysis of the radiation injury rate depending on the arteriovenous malformation volume. J Neurosurg 2008; 109:191-8. [PMID: 18671629 DOI: 10.3171/jns/2008/109/8/0191] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this paper the authors analyzed the clinical and neuroimaging outcomes of patients with cerebral arteriovenous malformations (AVMs) after Gamma Knife surgery (GKS), focusing on the analysis of the radiation injury rate depending on the AVM volume. METHODS Between 1997 and 2004, 277 consecutive patients with cerebral AVMs were treated with GKS. Of these patients, 218 were followed up for >or= 2 years. The mean age was 31 +/- 15 years, the median AVM volume was 3.4 cm3 (range 0.17-35.2 cm3), the median marginal dose was 18.0 Gy (range 10.0-25.0 Gy), and the mean follow-up duration was 44 +/- 20 months. The authors reduced the prescription dose by various amounts, depending on the AVM volume and location as prescribed in the classic guideline to avoid irreversible radiation injuries. RESULTS The angiographic obliteration rate was 66.4% overall, and it was 81.7, 53.1, and 12.5% for small, medium, and large AVMs, respectively. The overall annual bleeding rate was 1.9%. The annual bleeding rate was 0.44 and 4.64% for small and large AVMs, respectively. Approximately 20% of the patients showed severe postradiosurgery imaging (PRI) changes. The rate of PRI change was 11.4, 33.3, and 9.5% for small, medium, and large AVM volume groups, respectively, and a permanent radiation injury developed in 5.1% of patients. CONCLUSIONS By using the reduced dose from what is usually prescribed, the authors were able to obtain outcomes in small AVMs that were comparable to the outcomes described in previous reports. However, medium AVMs appear to still be at risk for adverse radiation effects. Last, in large AVMs, the authors were able to attain a tolerable rate of radiation injury; however, the clinical outcomes were quite disappointing following administration of a reduced dose of GKS for large AVMs.
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Affiliation(s)
- Jung Ho Han
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
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32
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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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33
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Liscák R, Vladyka V, Simonová G, Urgosík D, Novotný J, Janousková L, Vymazal J. ARTERIOVENOUS MALFORMATIONS AFTER LEKSELL GAMMA KNIFE RADIOSURGERY. Neurosurgery 2007; 60:1005-14; discussion 1015-6. [PMID: 17538373 DOI: 10.1227/01.neu.0000255474.60505.4a] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Although relevant information exists regarding the chance of obliterating arteriovenous malformations (AVMs) using radiosurgery, the overall chance of cure after gamma knife radiosurgery is usually only extrapolated from a portion of all monitored patients. This chance and the risks involved in radiosurgery, including repeat treatment when necessary in a defined population of treated patients, were analyzed in our study.
METHODS
Between October 1992 and June 2000, gamma knife radiosurgery was performed on 330 patients with AVMs. The volume of the AVM nidus ranged from 0.15 to 28.6 cm3 (median, 3.9 cm3). When complete obliteration was not achieved within 3 years, repeat radiosurgery was performed on 76 patients. The volume of the nidus for the second treatment ranged from 0.09 to 16.8 cm3 (median 2.9 cm3). The result was reviewed in 300 (91%) patients after the first round of treatment and in 68 (89.5%) after the second round of treatment.
RESULTS
AVM obliteration was achieved in 222 (74%) patients after the first round of radiosurgery and in 47 (69%) after the second. The overall chance of cure was 92% (269 patients). Final angiography verified complete obliteration by 12 to 96 months (median, 25 mo) after initial radiosurgery. Smaller volume AVMs and the application of a higher radiation dose resulted in a higher chance of obliteration. The risk of rebleeding after radiosurgery was 2.1% annually until full obliteration, and the overall mortality from rebleeding was 1%. The risk of permanent morbidity after the first and second radiosurgery treatments were 2.7 and 2.9%, respectively. The cumulative risk of morbidity in both groups of patients was 3.4%.
CONCLUSION
Although one-quarter of the patients required that the treatment be repeated, gamma knife radiosurgery can offer a high cure rate for patients treated for AVMs with a low risk of morbidity and mortality from rebleeding during the latent period.
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Affiliation(s)
- Roman Liscák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
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34
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Tu J, Stoodley MA, Morgan MK, Storer KP. Responses of arteriovenous malformations to radiosurgery: ultrastructural changes. Neurosurgery 2006; 58:749-58; discussion 749-58. [PMID: 16575339 DOI: 10.1227/01.neu.0000192360.87083.90] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the ultrastructural changes in arteriovenous malformations (AVMs) after radiosurgery and to explore the possible mechanisms of posttreatment obliteration and hemorrhage. METHODS Twenty-two specimens, among them three irradiated AVMs (size, 3-6 cm), 15 nonirradiated AVMs, and four normal controls were processed for ultrastructural study immediately after removal. Transmission electron microscopy was used to compare the vasculature of irradiated AVMs with nonirradiated AVMs and normal controls. RESULTS Thirty-three months postradiosurgery, partial vaso-occlusion (36-74% lumen) occurred by coagulation of cytoplasmic debris and proteinaceous material leaking from the endothelium. Forty-eight months postradiosurgery, heterogeneous thrombus formation (86-96% lumen) with fibrinoid and proteinaceous materials was observed. Sixty-four months postradiosurgery, complete luminal closure (90-100% lumen) by a fibrin thrombus was seen in vessels with diameters up to 5.5 mm including feeding arteries and draining veins. In occluded vessels, there was extensive degeneration of endothelial cells, subendothelial fibroblasts, and myofibroblasts. Neoproliferation and endothelialization of smooth muscle cells with Weibel-Palade bodies was observed in arteries. CONCLUSION Radiosurgery causes irreversible cellular damage of the vascular wall. Partial vaso-occlusion that increases blood flow in remaining vessels and degenerative changes on the blood-brain barrier may contribute to hemorrhage at early stage postradiosurgery. Radiosurgery stimulates neoproliferating and endothelializing smooth muscle cells in vessel walls, which might lead to narrowing of the vessel lumina. Complete vaso-occlusion achieved 64 months postradiosurgery suggested a minimum follow-up duration of 5 years to determine final outcome of radiosurgery. Histological end point of vaso-occlusion of AVMs takes longer time than neuroimaging endpoint of complete obliteration.
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Affiliation(s)
- Jian Tu
- Prince of Wales Medical Research Institute, University of New South Wales, Randwick, Australia
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35
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Jahan R, Solberg TD, Lee D, Medin P, Tateshima S, Sayre J, De Salles A, Vinters HV, Vinuela F. Stereotactic Radiosurgery of the Rete Mirabile in Swine: A Longitudinal Study of Histopathological Changes. Neurosurgery 2006; 58:551-8; discussion 551-8. [PMID: 16528197 DOI: 10.1227/01.neu.0000197335.93538.bd] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Stereotactic radiosurgery is an established, effective treatment for brain arteriovenous malformations. The mechanisms of vessel occlusion in arteriovenous malformations has not been extensively evaluated. To better understand these mechanisms, we report histopathological changes in the swine rete mirabile after stereotactic radiosurgery.
METHODS:
Thirty-five swine were used, 15 as nonradiated controls and 20 as radiated. Two in the control group and five in the radiated group were sacrificed before the study endpoint. Tissue was obtained from 13 nonradiated (4 at 3 mo, 5 at 6 mo, 4 at 9 mo) and 15 radiated swine (2 at 3 mo, 3 at 6 mo, 10 at 9 mo) for histological, immunohistochemical, and morphometric analysis.
RESULTS:
Radiated vessels showed increasing intimal hyperplasia over the follow-up period. Histometrical analysis confirmed this with evidence of progressive luminal narrowing over the follow-up period. Immunohistochemical analysis showed intimal cells to be proliferating smooth muscle cells with surrounding extracellular collagen Type IV. Adventitial fibrosis composed of collagen Type IV was also seen with smooth muscle cells interspersed within the collagen matrix. The nonradiated animals showed no intimal hyperplasia or change in the appearance or size of the vessels over the same follow-up period. Adventitial fibrosis was minimal in the nonradiated animals.
CONCLUSION:
The vessels show an intimal response to radiation with progressive occlusion caused by migrating, proliferating smooth muscle cells, a likely source of the extracellular collagen in the intima. Cytokine mediated pathways likely produce these morphological changes. Future studies will be directed toward elucidating these underlying molecular mechanisms.
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Affiliation(s)
- Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
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