scholarly journals P03.08 Large cerebral arteriovenous malformations management with Volume-staged gamma knife radiosurgery

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii26-iii26
Author(s):  
R M Emad Eldin ◽  
W A Reda ◽  
A M El-Shehaby ◽  
K Abdel Karim ◽  
A Nabeel ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations ◽  
Factors Affecting ◽  
Prescription Dose ◽  
The Mean ◽  
Cerebral Avms ◽  
Grade 3

Abstract BACKGROUND Large cerebral arteriovenous malformations (AVM) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged gamma knife radiosurgery (VSGR) has been developed for the treatment of large AVMs, to increase the efficacy and improve safety of treatment of these lesions. The aim of the study was to assess the efficacy and safety of VSGR technique for the treatment of large cerebral AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All cases had large AVMs (>10 cc). These were 29 patients. RESULTS Twenty-four patients completed radiographic follow up with 15 obliteration cases (62.5%). There was a total of 56 sessions performed. The mean AVM volume was 16 cc (10.1–29.3 cc). The mean prescription dose was 18 Gy (14–22 Gy). The mean follow up duration was 43 months (21–73 months). One patient died during follow up from unrelated cause. Two cases suffered haemorrhage during follow up. Symptomatic edema developed in 5 (17%) patients. The factors affecting obliteration were smaller total volume, higher dose/stage, non-deep location, compact AVM, AVM score less than 3, >18 Gy dose and <15 cc total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (p 0.012). T2 image changes were affected by SM grade 3 or more (p 0.013) and AVM score 3 or more (p 0.014). CONCLUSION VSGR provides an effective and safe treatment option for large cerebral AVMs. Smaller AVM volume is associated with higher obliteration rate.

scholarly journals Curative Glubran 2 Embolization of Cerebral Arteriovenous Malformations Patient Selection and Initial Results

2014 ◽  
Vol 20 (6) ◽  
pp. 722-728 ◽  
Author(s):  
Jie Liu ◽  
Ming Lv ◽  
Xianli Lv ◽  
Hongwei He ◽  
Aihua Liu ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Clinical Results ◽  
Hemorrhagic Complication ◽  
Cerebral Arteriovenous Malformations ◽  
Complete Obliteration ◽  
Glubran 2 ◽  
Cerebral Avms

The liquid embolic agents currently used for embolization of cerebral arteriovenous malformations are Onyx and NBCA. Glubran 2, a cyanoacrylate-based synthetic glue, has recently been applied for embolization of cerebral arteriovenous malformations (AVMs). We report the clinical results of selected cerebral AVMs treated with Glubran 2 targeting for curative embolization. Between October 2011 and March 2013, 31 patients with cerebral AVMs were selected for curative embolization with Glubran 2. There were 19 men and 12 women with a mean age of 32 years (range 4–65 years). Initial clinical presentation included hemorrhage in 28 and seizures in three patients. AVM location was frontal in eight patients, parietal in four, occipital in eight temporal in six, cerebellar in two and cerebellar vermis in three patients. Follow-up was performed clinically and with angiography examination at three to six months. Clinical outcomes were evaluated based on the modified Rankin Scale (mRS). A mean of 2.5 (range, 1–12) feeding pedicles were embolized per patient. Complete angiographic obliteration of AVM was achieved in 27 patients. A hemorrhagic complication was observed in one patient, an ischemic complication in one patient and technical complications in four patients. There was no procedure-related disabling neurological deficit or death at discharge. Additional gamma knife radiosurgery was performed in five patients, including one patient with recurrent AVM. All of the patients had favorable clinical outcomes at three to six month follow-up (mRS≤2). The curative embolization technique with Glubran 2 for selected cerebral AVMs achieved a high initial complete obliteration rate with an acceptable complication frequency.

Analysis of the causes of treatment failure in gamma knife radiosurgery for intracranial arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 104-106 ◽  
Author(s):  
Yang Kwon ◽  
Sang Ryong Jeon ◽  
Jeong Hoon Kim ◽  
Jung Kyo Lee ◽  
Dong Sook Ra ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Treatment Failure ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Intracranial Arteriovenous Malformations ◽  
Content Type ◽  
The Mean ◽  
Fine Print

Object. The authors sought to analyze causes for treatment failure following gamma knife radiosurgery (GKS) for intracranial arteriovenous malformations (AVMs), in cases in which the nidus could still be observed on angiography 3 years postsurgery. Methods. Four hundred fifteen patients with AVMs were treated with GKS between April 1990 and March 2000. The mean margin dose was 23.6 Gy (range 10–25 Gy), and the mean nidus volume was 5.3 cm3 (range 0.4–41.7 cm3). The KULA treatment planning system and conventional subtraction angiography were used in treatment planning. One hundred twenty-three of these 415 patients underwent follow-up angiography after GKS. After 3 years the nidus was totally obliterated in 98 patients (80%) and partial obliteration was noted in the remaining 25. There were several reasons why complete obliteration was not achieved in all cases: inadequate nidus definition in four patients, changes in the size and location of the nidus in five patients due to recanalization after embolization or reexpansion after hematoma reabsorption, a large AVM volume in five patients, a suboptimal radiation dose to the thalamic and basal ganglia in eight patients, and radioresistance in three patients with an intranidal fistula. Conclusions. The causes of failed GKS for treatment of AVMs seen on 3-year follow-up angiograms include inadequate nidus definition, large nidus volume, suboptimal radiation dose, recanalization/reexpansion, and radioresistance associated with an intranidal fistula.

Staged radiosurgery for extra-large cerebral arteriovenous malformations: method, implementation, and results

2008 ◽  
Vol 109 (Supplement) ◽  
pp. 65-72 ◽  
Author(s):  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Hsiu-Mei Wu ◽  
Kang-Du Liu ◽  
Wan-Yuo Guo ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Arteriovenous Malformations ◽  
High Signal ◽  
Minor Bleeding ◽  
Cerebral Arteriovenous Malformations ◽  
Presenting Symptoms ◽  
Second Stage ◽  
The Mean ◽  
Cerebral Avms

Object The effectiveness and safety of radiosurgery for small- to medium-sized cerebral arteriovenous malformations (AVMs) have been well established. However, the management for large cerebral AVMs remains a great challenge to neurosurgeons. In the past 5 years the authors performed preplanned staged radiosurgery to treat extra-large cerebral AVMs. Methods An extra-large cerebral AVM is defined as one with nidus volume > 40 ml. The nidus volume of cerebral AVM is measured from the dose plan—that is, as being the volume contained within the best-fit prescription isodose. From January 2003 to December 2007, the authors treated 6 patients with extra-large AVMs by preplanned staged GKS. Staged radiosurgery is implemented by rigid transformation with translation and rotation of coordinates between 2 stages. The average radiation-targeted volume was 60 ml (range 47–72 ml). The presenting symptoms were seizure in 4 patients and a bleeding episode in 2. One patient had undergone a previous craniotomy and evacuation of hematoma. The mean interval between the 2 radiosurgical sessions was 6.9 months (range 4.5–9.1 months). The prescribed marginal dose given to the nidus volume in each stage ranged from 16 to 18.6 Gy. The expected marginal dose of total nidus was 17–19 Gy. Regular follow-up MR imaging was performed every 6 months. The mean follow-up period was 28 months (range 12–54 months). Results Most of the patients exhibited clinical improvement: relief of headache and reduced frequency of seizure attack. All patients had significant regression of nidus observed on MR imaging follow-up. Two patients had angiogram-confirmed complete obliteration of the nidus 45 and 60 months after the second-stage radiosurgical session. One patient experienced minor bleeding 8 months after the second-stage radiosurgery with mild headache. She had satisfactory recovery without clinical neurological deficit after conservative treatment. Conclusions These preliminary results indicate that staged radiosurgery is a practical strategy to treat patients with extra-large cerebral AVMs. It takes longer to obliterate the AVMs. The observed high signal T2 changes after the radiosurgery appeared clinically insignificant in 6 patients followed up for an average of 28 months. Longer follow-up is necessary to confirm its long-term safety.

scholarly journals Low Dose Gamma-knife Radiosurgery for Diffuse Brainstem Gliomas

2018 ◽  
Vol 25 (3) ◽  
pp. 217-225
Author(s):  
Julio C. Antico ◽  
Daniel Benzecry Almeida
Keyword(s):  
Effective Treatment ◽  
Gamma Knife ◽  
Tumor Size ◽  
Radiation Effects ◽  
Gamma Knife Radiosurgery ◽  
Prescription Dose ◽  
Brainstem Tumors ◽  
The Mean ◽  
Early Late

Introduction: Diffuse brainstem glial tumors remain a challenge. Despite many advances in neurosurgical techniques, no effective treatment is currently available. Recently, some authors showed beneficial results with gamma-knife radiosurgery (GK) for focal brainstem tumors. Objective: to analyze safety and effectiveness of GK in patients with diffuse brainstem gliomas. Methods: Eleven patients with diffuse brainstem gliomas treated with Gamma-knife from November 2001 to June 2009 were included. Complete data such as age, gender, symptoms, tumor size, prescription dose, adverse radiation effects and an early late follow-up were analyzed. Results: The mean age was 28.7 years (ranging from 1y 7m to 62y). Six patients were female and 5 were male. The gamma-knife prescription dose ranged from 6 to 7 Gy. All patients had clinical and imaging improvement at an early follow-up, although in 6, there was a late increase in tumor size and death. The others remained clinically stable or better. Larger tumors had a direct relationship with a poorer prognosis. No patient developed complications related to the radiosurgical treatment. Conclusion: Gamma-Knife is a safe and effective treatment for selected patients with diffuse brainstem tumors. The authors propose lower doses. Further studies are mandatory in order to analyze which patients could benefit from this treatment.

scholarly journals Gamma Knife Radiosurgery for Pediatric Arteriovenous Malformations: A Canadian Experience

2015 ◽  
Vol 43 (1) ◽  
pp. 82-86 ◽  
Author(s):  
Fred A. Zeiler ◽  
Maciej K. Janik ◽  
Patrick J. McDonald ◽  
Anthony M. Kaufmann ◽  
Derek Fewer ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Treatment Option ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Complication Rates ◽  
Invasive Treatment ◽  
Effective Treatment Option ◽  
Dexamethasone Therapy ◽  
The Mean

AbstractBackground:Gamma Knife (GK) radiosurgery for pediatric arteriovenous malformations (AVM) of the brain presents a non-invasive treatment option. We report our institutional experience with GK for pediatric AVMs.Methods:We performed a retrospective review of all pediatric patients treated with GK for cerebral AVMs at our institution from November 2003 up to and including September 2014. Patient demographics, AVM characteristics, treatment parameters and AVM responses were recorded.Results:Nineteen patients were treated, with 4 lost to follow-up. The mean age was 14.2 years (range. 7-18 years), with 10 being males (52.6%). The mean AVM diameter and volume were 2.68 cm and 3.10 cm3respectively. The mean Spetzler-Martin (SM) and Pollock grades of the treated AVMs were 2.4 and 0.99 respectively. The mean follow-up was 62 months. All AVMs treated demonstrated a response on follow-up imaging. Nine of 15 (60.0%) patients displayed obliteration of their AVMs. Nine of 11 patients with a minimum of 3 years follow-up (81.8%) displayed obliteration, with SM and Pollock grades correlating to the chance of obliteration in this group. Two patients developed post-GK edema requiring short course dexamethasone therapy. No other major complications occurred. No permanent complications occurred.Conclusions:GK radiosurgery for pediatric AVMs offers a safe and effective treatment option, with low permanent complication rates during early follow-up.

Subtotal obliteration of cerebral arteriovenous malformations after Gamma Knife surgery

2007 ◽  
Vol 106 (3) ◽  
pp. 361-369 ◽  
Author(s):  
Chun Po Yen ◽  
Peter Varady ◽  
Jason Sheehan ◽  
Melita Steiner ◽  
Ladislau Steiner
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Surgery ◽  
Cerebral Arteriovenous Malformations ◽  
Peripheral Dose ◽  
Risk Of Bleeding ◽  
The Mean ◽  
Risk Of Hemorrhage ◽  
Early Filling

Object Subtotal obliteration of cerebral arteriovenous malformations (AVMs) after Gamma Knife surgery (GKS) implies a complete angiographic disappearance of the AVM nidus but persistence of an early filling draining vein, indicating that residual shunting is still present; hence, per definition there is still a patent AVM and the risk of bleeding is not eliminated. The aim of this study was to determine the risk of hemorrhage for patients with subtotal obliteration of AVMs. Methods After GKS for cerebral AVMs, follow-up angiography demonstrated a subtotally obliterated lesion in 159 patients. Of these, in 16 patients a subtotally obliterated AVM developed after a second GKS was performed for the partially obliterated lesion. The mean age of these patients was 35.2 years at the time of the diagnosis of subtotally obliterated AVMs. The lesion volumes at the time of initial GKS treatment ranged from 0.1 to 11.5 cm3 (mean 2.5 cm3). The mean peripheral dose used in the 175 GKS treatments was 22.5 Gy (median 23 Gy, range 15–31 Gy). To achieve total obliteration of the AVM, 23 patients underwent a new GKS targeting the proximal end of the early filling vein. The mean peripheral dose given in these cases was 23 Gy (median 24, range 18–25 Gy). The incidence of subtotally obliterated AVMs was 7.6% from a total of 2093 AVMs treated and in which follow-up imaging was available. The diagnosis of subtotally obliterated AVMs was made a mean of 29.4 months (range 4–178 months) after GKS. The number of patient-years at risk (from the time of the diagnosis of subtotally obliterated AVMs until either the confirmation of a total obliteration of the lesion on angiography or the time of the latest follow-up angio-graphic study that still visualized the early filling vein) was a mean of 3.9 years, ranging from 0.5 to 13.5 years, and a total of 601 patient-years. There was no case of bleeding after the diagnosis of subtotally obliterated AVMs. Of 90 patients who did not undergo further treatment and in whom follow-up angiography studies were available, the same early filling veins still filled in 24 (26.7%), and the subtotally obliterated AVMs were subsequently obliterated in 66 patients (73.3%). In 19 patients who underwent repeated GKS for subtotally obliterated AVMs and in whom follow-up angiography studies were available, the AVMs were obliterated in 15 (78.9%) and remained patent in four (21.1%). Conclusions The fact that none of the patients with subtotally obliterated AVMs suffered a rupture is not compatible with the assumption of an unchanged risk of hemorrhage for these lesions, and implies that the protection from re-bleeding in patients with subtotal obliteration is significant. Subtotal obliteration does not necessarily seem to be a stage of an ongoing obliteration. At least in some cases it represents an end point of this process, with no subsequent obliteration occurring. This observation requires further confirmation by open-ended follow-up imaging.

scholarly journals Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort

2017 ◽  
Vol 126 (1) ◽  
pp. 36-44 ◽  
Author(s):  
Robert M. Starke ◽  
Hideyuki Kano ◽  
Dale Ding ◽  
John Y. K. Lee ◽  
David Mathieu ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Predictors Of Outcome ◽  
Cerebral Arteriovenous Malformations ◽  
Long Term Outcomes ◽  
Radiation Induced ◽  
Cerebral Avms ◽  
Grading Scales

OBJECTIVE In this multicenter study, the authors reviewed the results following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs), determined predictors of outcome, and assessed predictive value of commonly used grading scales based upon this large cohort with long-term follow-up. METHODS Data from a cohort of 2236 patients undergoing GKRS for cerebral AVMs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and AVM characteristics were assessed to determine predictors of outcome, and commonly used grading scales were assessed. RESULTS The mean maximum AVM diameter was 2.3 cm, with a mean volume of 4.3 cm3. A mean margin dose of 20.5 Gy was delivered. Mean follow-up was 7 years (range 1–20 years). Overall obliteration was 64.7%. Post-GRKS hemorrhage occurred in 165 patients (annual risk 1.1%). Radiation-induced imaging changes occurred in 29.2%; 9.7% were symptomatic, and 2.7% had permanent deficits. Favorable outcome was achieved in 60.3% of patients. Patients with prior nidal embolization (OR 2.1, p < 0.001), prior AVM hemorrhage (OR 1.3, p = 0.007), eloquent location (OR 1.3, p = 0.029), higher volume (OR 1.01, p < 0.001), lower margin dose (OR 0.9, p < 0.001), and more isocenters (OR 1.1, p = 0.011) were more likely to have unfavorable outcomes in multivariate analysis. The Spetzler-Martin grade and radiosurgery-based AVM score predicted outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment. CONCLUSIONS GKRS for cerebral AVMs achieves obliteration and avoids permanent complications in the majority of patients. Patient, AVM, and treatment parameters can be used to predict long-term outcomes following radiosurgery.

scholarly journals Biologically effective dose and prediction of obliteration of unruptured arteriovenous malformations treated by upfront Gamma Knife radiosurgery: a series of 149 consecutive cases

2020 ◽  
pp. 1-11 ◽  
Author(s):  
Constantin Tuleasca ◽  
Iulia Peciu-Florianu ◽  
Henri-Arthur Leroy ◽  
Maximilien Vermandel ◽  
Mohamed Faouzi ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Effective Dose ◽  
Dose Rate ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Biologically Effective Dose ◽  
Radiation Dose Rate ◽  
The Mean

OBJECTIVEArteriovenous malformations (AVMs) present no pathologic tissue, and radiation dose is confined in a clear targeted volume. The authors retrospectively evaluated the role of the biologically effective dose (BED) after Gamma Knife radiosurgery (GKRS) for brain AVMs.METHODSA total of 149 consecutive cases of unruptured AVMs treated by upfront GKRS in Lille University Hospital, France, were included. The mean length of follow-up was 52.9 months (median 48, range 12–154 months). The primary outcome was obliteration, and the secondary outcome was complication appearance. The marginal dose was 24 Gy in a vast majority of cases (n = 115, 77.2%; range 18–25 Gy). The mean BED was 220.1 Gy2.47 (median 229.9, range 106.7–246.8 Gy2.47). The mean beam-on time was 32.3 minutes (median 30.8, range 9–138.7 minutes). In the present series, the mean radiation dose rate was 2.259 Gy/min (median 2.176, range 1.313–3.665 Gy/min). The Virginia score was 0 in 29 (19.5%), 1 in 61 (40.9%), 2 in 41 (27.5%), 3 in 18 (12.1%), and 4 in 0 (0%) patients, respectively. The mean Pollock-Flickinger score was 1.11 (median 1.52, range 0.4–2.9). Univariate (for obliteration and complication appearance) and multivariate (for obliteration only) analyses were performed.RESULTSA total of 104 AVMs (69.8%) were obliterated at the last follow-up. The strongest predictor for obliteration was BED (p = 0.03). A radiosurgical obliteration score is proposed, derived from a fitted multivariable model: (0.018 × BED) + (1.58 × V12) + (−0.013689 × beam-on time) + (0.021 × age) − 4.38. The area under the receiver operating characteristic curve was 0.7438; after internal validation using bootstrap methods, it was 0.7088. No statistically significant relationship between radiation dose rate and obliteration was found (p = 0.29). Twenty-eight (18.8%) patients developed complications after GKRS; 20 (13.4%) of these patients had transient adverse radiological effects (perilesional edema developed). Predictors for complication appearance were higher prescription isodose volume (p = 0.005) and 12-Gy isodose line volume (V12; p = 0.001), higher Pollock-Flickinger (p = 0.02) and Virginia scores (p = 0.003), and lower beam-on time (p = 0.03).CONCLUSIONSThe BED was the strongest predictor of obliteration of unruptured AVMs after upfront GKRS. A radiosurgical score comprising the BED is proposed. The V12 appears as a predictor for both efficacy and toxicity. Beam-on time was illustrated as statistically significant for both obliteration and complication appearance. The radiation dose rate did not influence obliteration in the current analysis. The exact BED threshold remains to be established by further studies.

Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 113-119 ◽  
Author(s):  
D. Hung-Chi Pan ◽  
Wan-Yuo Guo ◽  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Yue-Cune Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Treatment ◽  
Gamma Knife Radiosurgery ◽  
Consecutive Series ◽  
Content Type ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
Fine Print

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

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