Endovascular Therapy Followed by Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

1995 ◽  
Vol 8 (6) ◽  
pp. 163-166
Author(s):  
Y. Arai ◽  
Y. Handa ◽  
H. Ishii ◽  
Y. Ueda ◽  
H. Uno ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
High Rate ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Increased Risk ◽  
Irradiation Therapy ◽  
Complete Obliteration ◽  
Vascular Structures

Pre-radiosurgical embolization was carried out using cyanoacrylate in seven of 13 patients with cerebral arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (SRS) with a linear accelerator (LINAC). The aim of embolization before SRS was the reduction of AVM volume and/or the elimination of vascular structures bearing an increased risk of haemorrhage. Staged-volume SRS was also performed in two patients because of residual irregular shaped nidus of AVMs even after the embolizations. Complete obliteration of the AVM nidus on angiogram was presented in five patients with embolizations (including one with staged-volume SRS) and in three of six patients with SRS alone, during follow-up periods after radiosurgery. No patients experienced haemorrhagic events after SRS. Although transient neurological symptoms were observed after embolizations in two patients, no permanent neurological deficits were presented in all patients with SRS. Pre-radiosurgical embolization may allow the effective influence on irradiation therapy in relatively large AVMs and promote more frequent obliteration in more small sized AVMs compared to those with SRS alone. However, further study must be needed to determine whether staged-volume SRS provides a high rate of AVM obliteration and its safeness.

scholarly journals Endovascular Therapy Followed by Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

2006 ◽  
Vol 12 (1_suppl) ◽  
pp. 163-166 ◽  
Author(s):  
Y. Arai ◽  
Y. Handa ◽  
H. Ishii ◽  
Y. Ueda ◽  
H. Uno ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
High Rate ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Increased Risk ◽  
Irradiation Therapy ◽  
Complete Obliteration ◽  
Vascular Structures

Pre-radiosurgical embolization was carried out using cyanoacrylate in seven of 13 patients with cerebral arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (SRS) with a linear accelerator (LINAC). The aim of embolization before SRS was the reduction of AVM volume and/or the elimination of vascular structures bearing an increased risk of haemorrhage. Staged-volume SRS was also performed in two patients because of residual irregular shaped nidus of AVMs even after the embolizations. Complete obliteration of the AVM nidus on angiogram was presented in five patients with embolizations (including one with staged-volume SRS) and in three of six patients with SRS alone, during follow-up periods after radiosurgery. No patients experienced haemorrhagic events after SRS. Although transient neurological symptoms were observed after embolizations in two patients, no permanent neurological deficits were presented in all patients with SRS. Pre-radiosurgical embolization may allow the effective influence on irradiation therapy in relatively large AVMs and promote more frequent obliteration in more small sized AVMs compared to those with SRS alone. However, further study must be needed to determine whether staged-volume SRS provides a high rate of AVM obliteration and its safeness.

scholarly journals Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes

2014 ◽  
Vol 14 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Matthew B. Potts ◽  
Sunil A. Sheth ◽  
Jonathan Louie ◽  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Target Volume ◽  
Neurological Deficits ◽  
Single Institution ◽  
Risks And Benefits ◽  
Scale Scores ◽  
Time Of Presentation

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

scholarly journals Gamma Knife surgery for incidental cerebral arteriovenous malformations

2014 ◽  
Vol 121 (5) ◽  
pp. 1015-1021 ◽  
Author(s):  
Chun-Po Yen ◽  
Dale Ding ◽  
Ching-Hsiao Cheng ◽  
Robert M. Starke ◽  
Mark Shaffrey ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Latency Period ◽  
Invasive Procedure ◽  
Gamma Knife Surgery ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Long Term Follow Up

Object A relatively benign natural course of unruptured cerebral arteriovenous malformations (AVMs) has recently been recognized, and the decision to treat incidentally found AVMs has been questioned. This study aims to evaluate the long-term imaging and clinical outcomes of patients with asymptomatic, incidentally discovered AVMs treated with Gamma Knife surgery (GKS). Methods Thirty-one patients, each with an incidentally diagnosed AVM, underwent GKS between 1989 and 2009. The nidus volumes ranged from 0.3 to 11.1 cm3 (median 3.2 cm3). A margin dose between 15 and 26 Gy (median 20 Gy) was used to treat the AVMs. Four patients underwent repeat GKS for still-patent AVM residuals after the initial GKS procedure. Clinical follow-up ranged from 24 to 196 months, with a mean of 78 months (median 51 months) after the initial GKS. Results Following GKS, 19 patients (61.3%) had a total AVM obliteration on angiography. In 7 patients (22.6%), no flow voids were observed on MRI but angiographic confirmation was not available. In 5 patients (16.1%), the AVMs remained patent. A small nidus volume was significantly associated with increased AVM obliteration rate. Thirteen patients (41.9%) developed radiation-induced imaging changes: 11 were asymptomatic (35.5%), 1 had only headache (3.2%), and 1 developed seizure and neurological deficits (3.2%). Two patients each had 1 hemorrhage during the latency period (116.5 risk years), yielding an annual hemorrhage rate of 1.7% before AVM obliteration. Conclusions The decision to treat asymptomatic AVMs, and if so, which treatment approach to use, remain the subject of debate. GKS as a minimally invasive procedure appears to achieve a reasonable outcome with low procedure-related morbidity. In those patients with incidental AVMs, the benefits as well as the risks of radiosurgical intervention will only be fully defined with long-term follow-up.

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.

Stereotactic radiosurgery for arteriovenous malformations of the brain

1991 ◽  
Vol 75 (4) ◽  
pp. 512-524 ◽  
Author(s):  
L. Dade Lunsford ◽  
Douglas Kondziolka ◽  
John C. Flickinger ◽  
David J. Bissonette ◽  
Charles A. Jungreis ◽  
...  
Keyword(s):  
Magnetic Resonance ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Neurological Deficits ◽  
Content Type ◽  
Complete Obliteration ◽  
Latency Interval ◽  
Subtotal Removal ◽  
The Brain ◽  
Fine Print

✓ Stereotactic radiosurgery successfully obliterates carefully selected arteriovenous malformations (AVM's) of the brain. In an initial 3-year experience using the 201-source cobalt-60 gamma knife at the University of Pittsburgh, 227 patients with AVM's were treated. Symptoms at presentation included prior hemorrhage in 143 patients (63%), headache in 104 (46%), and seizures in 70 (31%). Neurological deficits were present in 102 patients (45%). Prior surgical resection (resulting in subtotal removal) had been performed in 36 patients (16%). In 47 selected patients (21%), embolization procedures were performed in an attempt to reduce the AVM size prior to radiosurgery. The lesions were classified according to the Spetzler grading system: 64 (28%) were Grade VI (inoperable), 22 (10%) were Grade IV, 90 (40%) were Grade III, 43 (19%) were Grade II, and eight (4%) were Grade I. With the aid of computer imaging-integrated isodose plans for single-treatment irradiation, total coverage of the AVM nidus was possible in 216 patients (95%). The location and volume of the AVM were the most important factors for the selection of radiation dose. Magnetic resonance (MR) imaging was performed at 6-month intervals in 161 patients. Seventeen patients who had MR evidence of complete obliteration underwent angiography within 3 months of imaging: in 14 (82%) complete obliteration was confirmed. Complete angiographic obliteration was confirmed in 37 (80%) of 46 patients at 2 years, the earliest confirmation being 4 months (mean 17 months) after radiosurgery. The 2-year obliteration rates according to volume were: all eight (100%) AVM's less than 1 cu cm; 22 (85%) of 26 AVM's of 1 to 4 cu cm; and seven (58%) of 12 AVM's greater than 4 cu cm. Magnetic resonance imaging revealed postirradiation changes in 38 (24%) of 161 patients at a mean interval of 10.2 months after radiosurgery; only 10 (26%) of those 38 patients were symptomatic. In the entire series, two patients developed permanent new neurological deficits believed to be treatment-related. Two patients died of repeat hemorrhage at 6 and 23 months after treatment during the latency interval prior to obliteration. Stereotactic radiosurgery is an important method to obliterate AVM's, especially those previously considered inoperable. Success and complication risks are related to the AVM location and the volume treated.

Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm

2017 ◽  
Vol 10 (3) ◽  
pp. 258-267 ◽  
Author(s):  
John D Nerva ◽  
Jason Barber ◽  
Michael R Levitt ◽  
Jason K Rockhill ◽  
Danial K Hallam ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Complication Rate ◽  
Arteriovenous Malformations ◽  
Treatment Algorithm ◽  
Latency Period ◽  
Neurological Deficits ◽  
Brain Arteriovenous Malformations ◽  
Radiographic Outcomes ◽  
Ethylene Copolymer

BackgroundEmbolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial.ObjectiveTo compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone.MethodsSeventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication.ResultsForty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively.ConclusionPre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.

Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations

2007 ◽  
Vol 107 (5) ◽  
pp. 965-972 ◽  
Author(s):  
Shigeki Yamada ◽  
Yasushi Takagi ◽  
Kazuhiko Nozaki ◽  
Ken-ichiro Kikuta ◽  
Nobuo Hashimoto
Keyword(s):  
Risk Factors ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
University Hospital ◽  
Neurological Deficits ◽  
First Year ◽  
Cerebral Arteriovenous Malformations ◽  
Drainage Pattern ◽  
Bleeding Rate ◽  
Increased Risk

Object The aim of this study was to identify the natural history of untreated cerebral arteriovenous malformations (AVMs) and the risk factors for subsequent hemorrhage after an initial AVM diagnosis. Methods The authors studied 305 consecutive patients with AVMs at the Kyoto University Hospital between 1983 and 2005. These patients were followed up until the first subsequent hemorrhage, the start of any treatment, or the end of 2005. Possible risk factors that were investigated included age at initial diagnosis, sex, type of initial presentation, size and location of the AVM nidus, and the venous drainage pattern. Subsequent hemorrhage occurred in 26 patients from the hemorrhagic group during 380 patient–years, and in 16 patients from the nonhemorrhagic group during 512 patient–years. Results The annual bleeding rate in the hemorrhagic group was 6.84% after the initial hemorrhage; however, that rate decreased in the first 5 years (15.42% in the first year, 5.32% in the subsequent 4 years, and 1.72% in more than 5 years). In the nonhemorrhagic group (annual bleeding rate of 3.12%), the patients initially presenting with headaches (annual bleeding rate of 6.48%) or asymptomatic presentations (annual bleeding rate of 6.44%) had a higher risk for subsequent hemorrhage. Conversely, those patients presenting with seizures (annual bleeding rate of 2.20%) or neurological deficits (annual bleeding rate of 1.73%) had a lower risk. A significantly increased risk (p < 0.05) of rebleeding was found among children (hazard ratio [HR] = 2.69), females (HR = 2.93), or patients with deep-seated AVMs (HR = 3.07). Conclusions Children, females, and patients with deep-seated AVMs had a threefold increased risk of rebleeding after an initial cerebral AVM. This increased risk was highest in the first year after the initial hemorrhage, and thereafter gradually decreased.

scholarly journals Edema following Gamma Knife radiosurgery for parasagittal and parafalcine meningiomas

2015 ◽  
Vol 123 (5) ◽  
pp. 1287-1293 ◽  
Author(s):  
Jason P. Sheehan ◽  
Cheng-Chia Lee ◽  
Zhiyuan Xu ◽  
Colin J. Przybylowski ◽  
Patrick D. Melmer ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Progression Free Survival ◽  
High Rate ◽  
Tumor Control ◽  
Peritumoral Edema ◽  
Who Grade ◽  
Increased Risk

OBJECT Stereotactic radiosurgery (SRS) has been shown to offer a high probability of tumor control for Grade I meningiomas. However, SRS can sometimes incite edema or exacerbate preexisting edema around the targeted meningioma. The current study evaluates the incidence, timing, and degree of edema around parasagittal or parafalcine meningiomas following SRS. METHODS A retrospective review was undertaken of a prospectively maintained database of patients treated with Gamma Knife radiosurgery at the University of Virginia Health System. All patients with WHO Grade I parafalcine or parasagittal meningiomas with at least 6 months of clinical follow-up were identified, resulting in 61 patients included in the study. The median radiographic follow-up was 28 months (range 6–158 months). Rates of new or worsening edema were quantitatively assessed using volumetric analysis; edema indices were computed as a function of time following radiosurgery. Statistical methods were used to identify favorable and unfavorable prognostic factors for new or worsening edema. RESULTS Progression-free survival at 2 and 5 years was 98% and 90%, respectively, according to Kaplan-Meier analysis. After SRS, new peritumoral edema occurred or preexisting edema worsened in 40% of treated meningiomas. The median time to onset of peak edema was 36 months post-SRS. Persistent and progressive edema was associated with 11 tumors, and resection was undertaken for these lesions. However, 20 patients showed initial edema progression followed by regression at a median of 18 months after radiosurgery (range 6–24 months). Initial tumor volume greater than 10 cm3, absence of prior resection, and higher margin dose were significantly (p < 0.05) associated with increased risk of new or progressive edema after SRS. CONCLUSIONS Stereotactic radiosurgery offers a high rate of tumor control in patients with parasagittal or parafalcine meningiomas. However, it can lead to worsening peritumoral edema in a minority of patients. Following radiosurgery, transient edema occurs earlier than persistent and progressive edema. Longitudinal follow-up of meningioma patients after SRS is required to detect and appropriately treat transient as well as progressive edema.

scholarly journals Natural history of brain arteriovenous malformations: a systematic review

2014 ◽  
Vol 37 (3) ◽  
pp. E7 ◽  
Author(s):  
Isaac Josh Abecassis ◽  
David S. Xu ◽  
H. Hunt Batjer ◽  
Bernard R. Bendok
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Cerebral Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Increased Risk ◽  
Risk Of Rupture ◽  
History Of ◽  
Arterial Aneurysms

Object The authors aimed to systematically review the literature to clarify the natural history of brain arteriovenous malformations (BAVMs). Methods The authors searched PubMed for one or more of the following terms: natural history, brain arteriovenous malformations, cerebral arteriovenous malformations, and risk of rupture. They included studies that reported annual rates of hemorrhage and that included either 100 patients or 5 years of treatment-free follow-up. Results The incidence of BAVMs is 1.12–1.42 cases per 100,000 person-years; 38%–68% of new cases are first-ever hemorrhage. The overall annual rates of hemorrhage for patients with untreated BAVMs range from 2.10% to 4.12%. Consistently implicated in subsequent hemorrhage are initial hemorrhagic presentation, exclusively deep venous drainage, and deep and infrantentorial brain location. The risk for rupture seems to be increased by large nidus size and concurrent arterial aneurysms, although these factors have not been studied as thoroughly. Venous stenosis has not been implicated in increased risk for rupture. Conclusions For patients with BAVMs, although the overall risk for hemorrhage seems to be 2.10%–4.12% per year, calculating an accurate risk profile for decision making involves clinical attention and accounting for specific features of the malformation.

Stereotactic radiosurgery for postgeniculate visual pathway arteriovenous malformations

1996 ◽  
Vol 84 (3) ◽  
pp. 437-441 ◽  
Author(s):  
Bruce E. Pollock ◽  
L. Dade Lunsford ◽  
Douglas Kondziolka ◽  
David J. Bissonette ◽  
John C. Flickinger
Keyword(s):  
Stereotactic Radiosurgery ◽  
Visual Function ◽  
Arteriovenous Malformations ◽  
Striate Cortex ◽  
Visual Pathway ◽  
Visual Field Defects ◽  
Content Type ◽  
Complete Obliteration ◽  
Fine Print

✓ Arteriovenous malformations (AVMs) that are located within the postgeniculate optic radiations or striate cortex are difficult to resect without creating postoperative visual defects. To reduce the risk of an AVM hemorrhage and to enhance the possibility of preserving visual function, the authors performed stereotactic radiosurgery in 34 patients with newly diagnosed or residual AVMs of the visual pathways. The mean AVM volume was 4.7 ml, and the average radiation dose to the AVM margin was 21 Gy. The median follow up was 47 months (range 16–83 months). Two (6%) of 34 patients had documented new visual field defects (central scotoma in one, and partial hemianopsia in one) after single-stage radiosurgery, but no patient developed a new permanent homonymous hemianopsia. Angiography was performed in all patients at a median of 26 months after radiosurgery: 22 (65%) had complete obliteration, 10 (29%) had a significant decrease in AVM volume, one (3%) had only a persistent early draining vein without residual nidus, and one (3%) had no change in the AVM. Thirteen (81%) of 16 patients with AVMs less of than 4 ml had complete obliteration. Five patients had second-stage stereotactic radiosurgery after angiography revealed a persistent AVM nidus; two patients eligible for follow-up angiography had complete obliteration, thereby increasing the overall series obliteration rate to 71%. The calculated annual risk of AVM bleeding (before radiographic evidence of obliteration) was 2.4%. No patient bled after angiographically confirmed obliteration. In most patients stereotactic radiosurgery obliterates visual pathway AVMs and also preserves preoperative visual function. Multimodality management (embolization, microsurgery, or staged radiosurgery) enhances AVM obliteration and visual preservation rates.

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