Stereotactic radiosurgery with and without embolization for intracranial arteriovenous malformations: a systematic review and meta-analysis

2014 ◽  
Vol 37 (3) ◽  
pp. E16 ◽  
Author(s):  
Feng Xu ◽  
Junjie Zhong ◽  
Abhishek Ray ◽  
Sunil Manjila ◽  
Nicholas C. Bambakidis
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Meta Analysis ◽  
Neurological Deficits ◽  
Current Evidence ◽  
Secondary Outcome ◽  
Intracranial Arteriovenous Malformations ◽  
Obliteration Rate ◽  
Radiation Induced ◽  
Induced Changes

Object The effectiveness and risk of stereotactic radiosurgery (SRS) in the management of partially embolized intracranial arteriovenous malformations (AVMs) remain controversial. The aim of this analysis was to assess current evidence regarding the efficiency and safety of SRS for AVM patients with and without prior embolization. Methods To compare SRS in patients with and without embolization, the authors conducted a meta-analysis of studies by searching the literature via PubMed and EMBASE for the period between January 2000 and December 2013, complemented by a hand search. Primary outcome was the rate of AVM obliteration on a 3-year follow-up angiogram. Secondary outcome was the rate of hemorrhage at 3 years after SRS. Tertiary outcome was permanent neurological deficits related to radiation-induced changes. Results Ten studies eligible for analysis included 1988 patients: 593 had undergone embolization followed by SRS and 1395 had undergone SRS alone. The AVM obliteration rate was significantly lower in patients who had undergone embolization followed by SRS than in those who had undergone SRS alone (41.0% vs 59%, OR 0.46, 95% CI 0.37–0.56, p < 0.00001). However, the rates of hemorrhage (7.3% vs 5.6%, OR 1.17, 95% CI 0.74–1.83, p = 0.50) and permanent neurological deficits related to radiation-induced changes (3.3% vs 3.4%, OR 1.41, 95% CI 0.64–3.11, p = 0.39) were not significantly different between the two groups. Conclusions Embolization before SRS significantly decreases the AVM obliteration rate. However, there is no significant difference in the risk of hemorrhage and permanent neurological deficits after SRS alone and following embolization. Further validation by well-designed prospective or randomized cohort studies is still needed.

scholarly journals Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Zhiqun Jiang ◽  
Xuezhi Zhang ◽  
Xichen Wan ◽  
Minjun Wei ◽  
Yue Liu ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Meta Analysis ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Cochrane Library ◽  
Efficacy And Safety ◽  
Intracranial Arteriovenous Malformations ◽  
Obliteration Rate

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.

Radiosurgery for ruptured intracranial arteriovenous malformations

2014 ◽  
Vol 121 (2) ◽  
pp. 470-481 ◽  
Author(s):  
Dale Ding ◽  
Chun-Po Yen ◽  
Robert M. Starke ◽  
Zhiyuan Xu ◽  
Jason P. Sheehan
Keyword(s):  
Multivariate Analysis ◽  
Arteriovenous Malformations ◽  
Latency Period ◽  
Intracranial Arteriovenous Malformations ◽  
Available N ◽  
Obliteration Rate ◽  
Radiation Induced ◽  
Prescription Dose ◽  
Induced Changes

Object Ruptured intracranial arteriovenous malformations (AVMs) are at a significantly greater risk for future hemorrhage than unruptured lesions, thereby necessitating treatment in the majority of cases. In a retrospective, single-center study, the authors describe the outcomes after radiosurgery in a large cohort of patients with ruptured AVMs. Methods From an institutional review board–approved, prospectively collected AVM radiosurgery database, the authors identified all patients with a history of AVM rupture. They analyzed obliteration rates in all patients in whom radiological follow-up data were available (n = 639). However, to account for the latency period associated with radiosurgery, only those patients with more than 2 years of radiological follow-up and those with earlier AMV obliteration were included in the analysis of prognostic factors related to obliteration and complications. This resulted in a cohort of 565 patients with ruptured AVMs for whom data were analyzed; these patients had a median radiological follow-up of 57 months and a median age of 29 years. Twenty-one percent of the patients underwent preradiosurgery embolization. The median volume and prescription dose were 2.1 cm3 and 22 Gy, respectively. The Spetzler-Martin grade was III or higher in 56% of patients, the median radiosurgery-based AVM score was 1.08, and the Virginia Radiosurgery AVM Scale (RAS) score was 3 to 4 points in 44%. Survival and regression analyses were performed to determine obliteration rates over time and predictors of obliteration and complications. Results In the overall population of 639 patients with ruptured AVMs, the obliteration rate was 11.1% based on MRI only (71 of 639 patients), 56.0% based on angiography (358 of 639), and 67.1% based on combined modalities (429 of 639 patients). In the cohort of patients with 2 years of follow-up or an earlier AVM obliteration, the cumulative obliteration rate was 76% and the actuarial obliteration rates were 41% and 64% at 3 and 5 years, respectively. Multivariate analysis identified the absence of preradiosurgery embolization (p < 0.001), increased prescription dose (p = 0.001), the presence of a single draining vein (p = 0.046), no postradiosurgery-related hemorrhage (p = 0.007), and lower Virginia RAS score (p = 0.020) as independent predictors of obliteration. The annual risk of a hemorrhage occurring during the latency period was 2.0% and the rate of hemorrhage-related morbidity and mortality was 1.6%. Multivariate analysis showed that decreased prescription dose (p < 0.001) and multiple draining veins (p = 0.003) were independent predictors of postradiosurgery hemorrhage. The rates of symptomatic and permanent radiation-induced changes were 8% and 2.7%, respectively. In the multivariate analysis, a single draining vein (p < 0.001) and higher Virginia RAS score (p = 0.005) were independent predictors of radiation-induced changes following radiosurgery. Conclusions Radiosurgery effectively treats ruptured AVMs with an acceptably low risk-to-benefit ratio. For patients with ruptured AVMs, favorable outcomes are more likely when preradiosurgical embolization is avoided and a higher prescription dose can be delivered.

scholarly journals Repeat Gamma Knife Surgery for Incompletely Obliterated Cerebral Arteriovenous Malformations

Neurosurgery ◽  
2010 ◽  
Vol 67 (1) ◽  
pp. 55-64 ◽  
Author(s):  
Chun-Po Yen ◽  
Surbhi Jain ◽  
Iftikhar-ul Haq ◽  
Jay Jagannathan ◽  
David Schlesinger ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Surgery ◽  
Neurological Deficits ◽  
Resonance Imaging ◽  
Cerebral Arteriovenous Malformations ◽  
Radiation Induced ◽  
Induced Changes

Abstract OBJECTIVE The causes of failure after an initial Gamma procedure were studied, along with imaging and clinical outcomes, in a series of 140 patients with cerebral arteriovenous malformations (AVMs) treated with repeat Gamma Knife surgery (GKS). METHODS Causes of initial treatment failure included inaccurate nidus definition in 14 patients, failure to fill part of the nidus as a result of hemodynamic factors in 16, recanalization of embolized AVM compartments in 6, and suboptimal dose (&lt; 20 Gy) in 23. Nineteen patients had repeat GKS for subtotal obliteration of AVMs. In 62 patients, the AVM failed to obliterate despite correct target definition and adequate dose. At the time of retreatment, the nidus volume ranged from 0.1 to 6.9 cm3 (mean, 1.4 cm3), and the mean prescription dose was 20.3 Gy. RESULTS Repeat GKS yielded a total angiographic obliteration in 77 patients (55%) and subtotal obliteration in 9 (6.4%). In 38 patients (27.1%), the AVMs remained patent, and in 16 patients (11.4%), no flow voids were observed on magnetic resonance imaging. Clinically, 126 patients improved or remained stable, and 14 experienced deterioration (8 resulting from a rebleed, 2 caused by persistent arteriovenous shunting, and 4 related to radiation-induced changes). CONCLUSION By using repeat GKS, we achieved a 55% angiographic cure rate. Although radiation-induced changes as visualized on magnetic resonance imaging occurred in 48 patients (39%), only 4 patients (3.6%) developed permanent neurological deficits. These findings may be useful in deciding the management of AVMs in whom total obliteration after initial GKS was not achieved.

Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review

2018 ◽  
Vol 128 (1) ◽  
pp. 154-164 ◽  
Author(s):  
Adeel Ilyas ◽  
Ching-Jen Chen ◽  
Dale Ding ◽  
Davis G. Taylor ◽  
Shayan Moosa ◽  
...  
Keyword(s):  
Systematic Review ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Management Strategy ◽  
Individual Patient Data ◽  
Brain Arteriovenous Malformations ◽  
Large Brain ◽  
Radiation Induced ◽  
The Mean ◽  
Induced Changes

OBJECTIVESeveral recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs.METHODSA systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis.RESULTSA total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%–50.9%) and 32.3% (95% CI 15.9%–48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281).CONCLUSIONSVolume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.

104 Stereotactic Radiosurgery for Spetzler-Martin Grade IV and V Arteriovenous Malformations: An International Multicenter Study

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 220-221
Author(s):  
Jason P Sheehan ◽  
Mohana Rao Patibandla ◽  
Dale Ding ◽  
Hideyuki Kano ◽  
Zhiyuan Xu ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Independent Predictor ◽  
Multivariate Logistic Regression Analysis ◽  
Favorable Outcome ◽  
Single Session ◽  
Radiation Induced ◽  
International Multicenter Study ◽  
Induced Changes

Abstract INTRODUCTION Due to the complexity of Spetzler-Martin (SM) grade IV-V arteriovenous malformations (AVM), the management of these lesions remains controversial. The aims of this multicenter, retrospective study are to evaluate outcomes after single-session stereotactic radiosurgery (SRS) for SM grade IV-V AVMs and determine predictive factors. METHODS We pooled data from 233 patients (mean age 33 years) with SM grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at eight participating centers in the International Gamma Knife Research Foundation. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cc, 17.3 Gy, and 84.5 months, respectively. RESULTS >At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37% and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (P = 0.04) found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM grade IV-V AVMs compared to ruptured ones (P = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (P = 0.024) and radiologically evident RIC (P = 0.05) in multivariate analyses. CONCLUSION In this multi-institutional study, single session SRS had limited efficacy in the management of SM grade IV-V AVMs Favorable outcome was only achieved in a minority of unruptured SM grade IV-V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume staged SRS approach for large AVMs represents an alternative approach for high grade AVM’s, but it requires further investigation.

Radiosurgery for patients with unruptured intracranial arteriovenous malformations

2013 ◽  
Vol 118 (5) ◽  
pp. 958-966 ◽  
Author(s):  
Dale Ding ◽  
Chun-Po Yen ◽  
Zhiyuan Xu ◽  
Robert M. Starke ◽  
Jason P. Sheehan
Keyword(s):  
Arteriovenous Malformations ◽  
Cox Regression ◽  
Univariate Analysis ◽  
Cyst Formation ◽  
Intracranial Arteriovenous Malformations ◽  
Radiation Induced ◽  
Prescription Dose ◽  
Martin Grade ◽  
The Mean ◽  
Induced Changes

Object The appropriate management of unruptured intracranial arteriovenous malformations (AVMs) remains controversial. In the present study, the authors evaluate the radiographic and clinical outcomes of radiosurgery for a large cohort of patients with unruptured AVMs. Methods From a prospective database of 1204 cases of AVMs involving patients treated with radiosurgery at their institution, the authors identified 444 patients without evidence of rupture prior to radiosurgery. The patients' mean age was 36.9 years, and 50% were male. The mean AVM nidus volume was 4.2 cm3, 13.5% of the AVMs were in a deep location, and 44.4% were at least Spetzler-Martin Grade III. The median radiosurgical prescription dose was 20 Gy. Univariate and multivariate Cox regression analyses were used to determine risk factors associated with obliteration, postradiosurgery hemorrhage, radiation-induced changes, and postradiosurgery cyst formation. The mean duration of radiological and clinical follow-up was 76 months and 86 months, respectively. Results The cumulative AVM obliteration rate was 62%, and the postradiosurgery annual hemorrhage rate was 1.6%. Radiation-induced changes were symptomatic in 13.7% and permanent in 2.0% of patients. The statistically significant independent positive predictors of obliteration were no preradiosurgery embolization (p < 0.001), increased prescription dose (p < 0.001), single draining vein (p < 0.001), radiological presence of radiation-induced changes (p = 0.004), and lower Spetzler-Martin grade (p = 0.016). Increased volume and higher Pittsburgh radiosurgery-based AVM score were predictors of postradiosurgery hemorrhage in the univariate analysis only. Clinical deterioration occurred in 30 patients (6.8%), more commonly in patients with postradiosurgery hemorrhage (p = 0.018). Conclusions Radiosurgery afforded a reasonable chance of obliteration of unruptured AVMs with relatively low rates of clinical and radiological complications.

Gamma Knife surgery for arteriovenous malformations in children

2010 ◽  
Vol 6 (5) ◽  
pp. 426-434 ◽  
Author(s):  
Chun Po Yen ◽  
Stephen J. Monteith ◽  
James H. Nguyen ◽  
Jessica Rainey ◽  
David J. Schlesinger ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Cyst Formation ◽  
Gamma Knife Surgery ◽  
Neurological Deficits ◽  
Secondary Tumors ◽  
Radiation Induced ◽  
Induced Changes

Object The aim of this study was to evaluate the long-term imaging and clinical outcomes of intracranial arteriovenous malformations (AVMs) in children treated with Gamma Knife surgery (GKS). Methods Between 1989 and 2007, 200 patients with AVMs who were 18 years of age or younger were treated at the University of Virginia Health System. Excluding 14 patients who had not reached 2-year follow-up, 186 patients comprised this study. Hemorrhage was the most common presenting symptom leading to the diagnosis of AVMs (71.5%). The mean nidus volume was 3.2 cm3 at the time of GKS, and a mean prescription dose of 21.9 Gy was used. Results After initial GKS, 49.5% of patients achieved total angiographic obliteration. Forty-one patients whose AVM nidi remained patent underwent additional GKS. The obliteration rate increased to 58.6% after a second or multiple GKS. Subtotal obliteration was achieved in 9 patients (4.8%). Forty-nine patients (26.3%) still had a patent residual nidus. In 19 patients (10.2%), obliteration was confirmed on MR imaging only. Ten patients had 17 hemorrhages during the follow-up period. The hemorrhage rate was 5.4% within 2 years after GKS and 0.8% between 2 and 5 years. Six patients developed neurological deficits along with the radiation-induced changes. Two patients developed asymptomatic meningiomas 10 and 12 years after GKS. After a mean clinical follow-up of 98 months, less than 4% of patients had difficulty attending school or developing a career. Conclusions Gamma Knife surgery offers a reasonable chance of obliteration of an AVM in pediatric patients. The incidence of symptomatic radiation-induced changes is relatively low; however, long-term clinical and imaging follow-up is required to identify delayed cyst formation and secondary tumors.

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