Gamma Knife Radiosurgery for Incidental, Symptomatic Unruptured, and Ruptured Brain Arteriovenous Malformations

Background: This study was performed to investigate clinical characteristics and outcome after gamma knife radiosurgery (GKS) in patients with incidental, symptomatic unruptured, or ruptured arteriovenous malformations (AVMs). Methods: A total of 491 patients with brain AVMs treated with GKS from June 2002 to September 2017 were retrospectively reviewed. All patients were classified into the incidental (n = 105), symptomatic unruptured (n = 216), or ruptured AVM (n = 170) groups. Results: The mean age at diagnosis of incidental, symptomatic unruptured, and ruptured AVMs was 40.3, 36.7, and 27.6 years, respectively. The mean nidus volume was 3.9, 5.7, and 2.4 cm3, respectively. Deep venous drainage was identified in 34, 54, and 76% patients, respectively. There were no significant differences in obliteration rates after GKS between the 3 groups (64.8, 61.1, and 65.9%, respectively) after a mean follow-up period of 60.5 months; however, patients with incidental AVM had a significantly lower post-GKS hemorrhage rate than patients with symptomatic unruptured or ruptured AVMs (annual hemorrhage rate of 1.07, 2.87, and 2.69%; p = 0.028 and p = 0.049, respectively). Conclusions: There is a significant difference in clinical and anatomical characteristics between incidental, symptomatic unruptured, and ruptured AVMs. The obliteration rate after GKS is not significantly different between the 3 groups. Meanwhile, an older age at diagnosis and lower hemorrhage rate after GKS in incidental AVMs suggest that they have a more indolent natural course with a lower life-long risk of hemorrhage.

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Results for a Series of 697 Arteriovenous Malformations Treated by Gamma Knife

Neurosurgery ◽

10.1227/neu.0000000000000506 ◽

2014 ◽

Vol 75 (5) ◽

pp. 568-583 ◽

Cited By ~ 16

Author(s):

Laura Paúl ◽

Alfredo Casasco ◽

M. Elena Kusak ◽

Nuria Martínez ◽

Germán Rey ◽

...

Keyword(s):

Confidence Interval ◽

Gamma Knife ◽

Odds Ratio ◽

Arteriovenous Malformations ◽

Careful Study ◽

Obliteration Rate ◽

The Mean ◽

Risk Of Hemorrhage ◽

Brain Avms

Abstract BACKGROUND: Stereotactic radiosurgery (RS) is an effective tool in treating brain arteriovenous malformations (AVMs). Careful study of AVM angiographic characteristics may improve results. OBJECTIVE: To report the long-term outcomes of Gamma Knife RS (GKRS) in brain AVMs, focusing on how the angioarchitectural and hemodynamic parameters of AVMs affect the post-RS results. METHODS: This was a retrospective, longitudinal study of 697 consecutive GKRS treatments of brain AVMs in 662 patients performed at a single center between 1993 and 2005. The mean age of the patients was 37 years; the median AVM volume was 3.6 cm3; and the mean follow-up was 11 years. Forty-five percent of patients presented with intracranial hemorrhage; 44% underwent embolization; and 7% had multiple RSs. AVM characteristics in the RS-planning angiograms were analyzed, and their relationship to the post-RS obliteration rate was determined by univariate and multivariate analyses. RESULTS: The obliteration rate after a single RS was 69.3%; after multiple RS, it was 75%. Positive predictors of obliteration included compact nidus (odds ratio = 3.16; 95% confidence interval, 1.92-5.22), undilated feeders (odds ratio = 0.36; 95% confidence interval, 0.23-0.57), smaller AVM volume (odds ratio = 0.95; 95% confidence interval, 0.92-0.99), and higher marginal dose (odds ratio = 1.16; 95% confidence interval, 1.06-1.27). Improvement or clinical stability was observed in 89.3% of patients; postprocedural bleeding was noted in 6.1%; and clinical worsening attributable to RS was seen in 3.8%. The annual risk of hemorrhage in the 4 years after RS was 1.2%. CONCLUSION: GKRS yielded a good long-term clinical outcome in most patients. Certain angiographic features of brain AVMs such as a well-defined nidus and undilated feeder arteries contribute to AVM occlusion by RS. GKRS can be regarded as the treatment of choice for AVMs <6 cm3, even after bleeding.

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

Neuro-Oncology ◽

10.1093/neuonc/noz126.089 ◽

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.

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Endovascular Treatment Accounts for a Change in Brain Arteriovenous Malformation Natural History Risk

Interventional Neuroradiology ◽

10.1177/159101991001600203 ◽

2010 ◽

Vol 16 (2) ◽

pp. 127-132 ◽

Cited By ~ 20

Author(s):

X. Lv ◽

Z. Wu ◽

C. Jiang ◽

Y. Li ◽

X. Yang ◽

...

Keyword(s):

Arteriovenous Malformation ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Venous Drainage ◽

Endovascular Embolization ◽

Adjusted Relative Risk ◽

Brain Arteriovenous Malformation ◽

Kaplan Meier ◽

Complete Obliteration ◽

Risk Of Hemorrhage

This study estimated the risk and rates of intracranial hemorrhage (ICH) in patients harboring brain arteriovenous malformation (BAVM) after endovascular embolization. One hundred and forty-four consecutive patients with BAVM treated with endovascular embolization between 1998 and 2003 were retrospectively reviewed. The risk of ICH subsequent to endovascular embolization was studied using Kaplan-Meier curves. We reviewed 144 patients with BAVM treated with endovascular embolization. Two hundred and sixty-nine procedures were performed, 69 were performed with silk sutures, 18 with coils, 137 with NBCA and 36 with Onyx18. Twenty-three (16.0%) patients were treated with additional gamma-knife radiosurgery and one (0.7%) with additional surgical AVM excision. Complete obliteration of BAVMs was achieved in 20 patients (13.9%). During a mean follow-up of 5.9 years for the ICH group and 6.9 years for the non-ICH group, hemorrhages occurred in 11 (17.7%) of the ICH patients and in nine (11%) of the non-ICH group (p>0.1). The annual risk of hemorrhage was 3.0% and 1.6%, respectively. In the multivariate regression model, the adjusted relative risk (RR) for hemorrhage at initial presentation was 1.6 (95% CI 1.2–3.2; p>0.1). Deep venous drainage, male sex, age or AVM size were not significantly associated with subsequent hemorrhage. ICH and non-ICH groups did not differ in progression to subsequent ICH after endovascular embolization (log-rank X2 = 1.339, p>0.1) in survival analyses. The overall annual hemorrhage risk for all patients after endovascular embolization was 2.1%. Endovascular embolization alone or combined with gamma-knife radiosurgery or surgical treatment are able to decrease ICH occurrence compared to abstention.

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Stereotactic Gamma Knife Radiosurgery for Extracranial Arteriovenous Malformations

Stereotactic and Functional Neurosurgery ◽

10.1159/000509753 ◽

2020 ◽

Vol 98 (6) ◽

pp. 424-431

Author(s):

Michaela Dedeciusova ◽

Constantin Tuleasca ◽

Steven David Hajdu ◽

Luis Schiappacasse ◽

David Patin ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Treatment Method ◽

Complication Rates ◽

Historical Cohort ◽

Single Fraction ◽

First Case ◽

Stereotactic Frame ◽

Brain Avms

Introduction: Head and neck extracranial arteriovenous malformations (AVMs) are rare pathological conditions which pose diagnostic and reconstruction challenges. Stereotactic radiosurgery (SRS) is nowadays an established treatment method for brain AVMs, with high obliteration and low complication rates. Here we describe the first report of head extracranial AVMs successfully treated by Gamma Knife (GK) as a retrospective historical cohort. Methods: Over a 9-year period, 2 cases of extracranial AVMs were treated by GK Perfexion (Elekta Instruments AB, Stockholm, Sweden) at a single institution. A stereotactic frame and multimodal imaging, including digital subtraction angiography (DSA), were used. The prescribed dose was 24 Gy at the 50% isodose line. Results: The first case was of a patient with pulsating tinnitus and left superficial parotido-condylian AVM. Embolization achieved partial obliteration. Tinnitus disappeared during the following 6 months after GK. The second case was a patient with repetitive gingival hemorrhages and right superior maxillary AVM, fed by the right internal maxillary and facial arteries. Embolization achieved partial obliteration with recurrence of symptoms. GK was further performed. DSA confirmed complete obliteration in both patients. Conclusions: Single-fraction GK radiosurgery appears to be safe and effective for extracranial AVMs. We recommend prescribing doses that are comparable to the ones used for brain AVMs (i.e., 24 Gy). A stereotactic frame is an important tool to ensure higher accuracy in the context of these particular locations. However, in selected cases, a mask could be applied either for single fraction purposes (if in a non-mobile location) or for hypofractionation, in case of larger volumes. These findings should be validated in larger cohorts, inclusively in terms of dose prescription.

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

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0104 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 104-106 ◽

Cited By ~ 52

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.

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Outcome after hemorrhage following Gamma Knife surgery for cerebral arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2008.10.17675 ◽

2009 ◽

Vol 110 (5) ◽

pp. 1003-1009 ◽

Cited By ~ 10

Author(s):

Manish Kumar Kasliwal ◽

Shashank Sharad Kale ◽

Aditya Gupta ◽

Narayanam Anantha Sai Kiran ◽

Manish Singh Sharma ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Venous Drainage ◽

Venous Hypertension ◽

Gamma Knife Surgery ◽

New Delhi ◽

Cerebral Arteriovenous Malformations ◽

Complete Obliteration ◽

Cerebral Avms ◽

Risk Of Hemorrhage

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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Reappearance of arteriovenous malformations after complete resection of ruptured arteriovenous malformations: true recurrence or false-negative early postoperative imaging result?

Journal of Neurosurgery ◽

10.3171/2016.3.jns152846 ◽

2017 ◽

Vol 126 (4) ◽

pp. 1088-1093 ◽

Cited By ~ 14

Author(s):

Rabih Aboukaïs ◽

Matthieu Vinchon ◽

Mathilde Quidet ◽

Philippe Bourgeois ◽

Xavier Leclerc ◽

...

Keyword(s):

Cerebral Angiography ◽

Arteriovenous Malformations ◽

Pediatric Patients ◽

False Negative ◽

Latency Period ◽

Venous Drainage ◽

Microsurgical Treatment ◽

Imaging Result ◽

Ruptured Avm ◽

The Mean

OBJECTIVE Ruptured arteriovenous malformations (AVMs) are often obliterated after emergency microsurgical treatment. However, some studies have reported AVM recurrence after the obliteration of ruptured AVMs. The authors report their experience with AVM recurrence after successful microsurgical treatment of ruptured AVMs. METHODS The authors reviewed the medical data of 139 consecutive patients who underwent microsurgery at the authors' institution for ruptured AVM between 2002 and 2012. Each patient underwent a conventional cerebral angiography examination immediately after the surgery. Subsequent follow-ups were performed with MR angiography after 6 months, and, if there was no indication of AVM recurrence, patients were followed up with conventional cerebral angiography between 1 and 2 years after the treatment; pediatric patients were followed up until age 18 years. Recurrence was defined as new radiological evidence of an AVM at the site of a ruptured AVM or a new hemorrhage in patients with angiographically documented AVM obliteration on postoperative angiograms. RESULTS The mean age of the patients at the time of ruptured AVM diagnosis was 30.8 years (SD ± 5, range 4–69 years), and 44 of the patients were younger than 18 years (the mean age at diagnosis in this pediatric subgroup was 11.4 years [range 4–17.9 years]). Complete AVM obliteration after the initial microsurgery was observed in 123 patients (89.5%). Reappearance of an AVM was noted in 7 patients between 12 and 42 months after the treatment, and all of these patients were younger than 18 years. The recurrent AVM was located in an eloquent zone in 4 patients, and deep venous drainage was noted in 3 patients. Radiosurgery was performed in 6 of these patients, and 1 patient underwent another microsurgical procedure. The authors noted only one rebleeding due to an AVM recurrence during the latency period after radiosurgery. CONCLUSIONS The recurrence of an AVM is fairly rare and affects mostly pediatric patients. Therefore, especially in children, long-term angiographic follow-up is required to detect AVM recurrence or an AVM remnant. The authors stress the need for discussion involving a multidisciplinary neurosurgical team to decide on treatment in cases of any AVM recurrence or remnant.

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Gamma Knife Radiosurgery for Pediatric Arteriovenous Malformations: A Canadian Experience

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.267 ◽

2015 ◽

Vol 43 (1) ◽

pp. 82-86 ◽

Cited By ~ 10

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.

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Gamma knife radiosurgery for brainstem arteriovenous malformations: preliminary results

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0102 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 102-103 ◽

Cited By ~ 51

Author(s):

Nicolas Massager ◽

Jean Régis ◽

Douglas Kondziolka ◽

Théodore Njee ◽

Marc Levivier

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Female Ratio ◽

Content Type ◽

First Choice ◽

Male Female Ratio ◽

Dose Ranging ◽

The Mean ◽

Fine Print

Object. This study was undertaken to assess the efficacy and safety of gamma knife radiosurgery (GKS) for the treatment of arteriovenous malformations (AVMs) located within the brainstem. Methods. The results of GKS performed in 87 patients with brainstem AVMs at two centers with experienced physicians are reviewed. The mean patient age was 37 years and the population included 19 children. The male/female ratio was 56:31. The malformation was located in the upper brainstem in 52 patients. Seventy-four percent of the patients had suffered a hemorrhage before GKS. For 70% of the patients no other treatment had been proposed before GKS. The mean AVM volume was 1.3 cm3. The lesions were treated with one to eight isocenters, with a margin dose ranging between 11.5 Gy and 30 Gy. The mean clinical follow-up period was 3.2 years. Ninety-five percent of the patients improved or remained neurologically stable. Rebleeding occurred in three patients at 3, 6, and 16 months, respectively, after GKS. Two patients in whom rebleeding occured recovered, and one died. The AVM obliteration rate was 63% at 2 years and 73% at 3 years after GKS. A second GKS was performed in six patients in whom only partial obliteration was demonstrated on angiography 3 years after the first procedure. Conclusions. Gamma knife radiosurgery may be a valuable first-choice therapy for the treatment of AVMs located within the brainstem.

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Hemorrhage risks and obliteration rates of arteriovenous malformations after gamma knife radiosurgery

Journal of Neurosurgery ◽

10.3171/jns.2002.97.supplement_5.0474 ◽

2002 ◽

Vol 97 ◽

pp. 474-476 ◽

Cited By ~ 40

Author(s):

Hiroshi K. Inoue ◽

Chihiro Ohye

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Mixed Type ◽

Gamma Knife Radiosurgery ◽

Low Flow ◽

Deep Drainage ◽

Content Type ◽

Obliteration Rate ◽

Risk Of Hemorrhage ◽

Fine Print

Object. The purpose of this study was to analyze the risk of hemorrhage and the obliteration rate after treatment of patients with arteriovenous malformations (AVMs). Methods. Between 1991 and 1995, 115 patients were treated using gamma knife radiosurgery (GKS). Surgical planning was based on angiograms and three-dimensional images. The angiographic features of the AVMs and the risk factors for hemorrhage were then evaluated. Hemorrhages occurred in eight patients (7%) 7 to 42 months after GKS. Based on AVM morphology, the rates of hemorrhage were five (7.6%) of 66 for AVMs with a single draining vein, seven (14%) of 66 for AVMs with deep drainage, four (26.7%) of 15 for AVMs with a varix, four (28.6%) of 14 for AVMs with venous obstruction, eight (17.0%) of 47 for high-flow (shunt- and mixed-type) AVMs, and five (35.7%) of 14 for large AVMs with a volume of more than 10 cm3. No hemorrhages were observed in association with low-flow (moyamoya-type) AVMs in this series. Total AVM obliteration was achieved in 81.3% of 80 patients who underwent angiography. The obliteration rate was 91.3% for moyamoya-type AVMs and 67.6% for shunt- and mixed-type AVMs. Early obliteration within 12 months was achieved in 63% of the moyamoya-type AVMs. Conclusions. Moyamoya-type AVMs seem to be at risk for post-GKS hemorrhage. Intravascular embolization should be considered prior to GKS for mixed- and shunt-type AVMs in an attempt to reduce the hemodynamic stress and thereby decrease the risk of hemorrhage.

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