Early versus late arteriovenous malformation responders after stereotactic radiosurgery: an international multicenter study

OBJECTIVEThe goal of stereotactic radiosurgery (SRS) for arteriovenous malformation (AVM) is complete nidus obliteration, thereby eliminating the risk of future hemorrhage. This outcome can be observed within the first 18 months, although documentation of AVM obliteration can extend to as much as 5 years after SRS is performed. A shorter time to obliteration may impact the frequency and effect of post-SRS complications and latency hemorrhage. The authors' goal in the present study was to determine predictors of early obliteration (18 months or less) following SRS for cerebral AVM.METHODSEight centers participating in the International Gamma Knife Research Foundation (IGKRF) obtained institutional review board approval to supply de-identified patient data. From a cohort of 2231 patients, a total of 1398 patients had confirmed AVM obliteration. Patients were sorted into early responders (198 patients), defined as those with confirmed nidus obliteration at or prior to 18 months after SRS, and late responders (1200 patients), defined as those with confirmed nidus obliteration more than 18 months after SRS. The median clinical follow-up time was 63.7 months (range 7–324.7 months).RESULTSOutcome parameters including latency interval hemorrhage, mortality, and favorable outcome were not significantly different between the 2 groups. Radiologically demonstrated radiation-induced changes were noted more often in the late responder group (376 patients [31.3%] vs 39 patients [19.7%] for early responders, p = 0.005). Multivariate independent predictors of early obliteration included a margin dose > 24 Gy (p = 0.031), prior surgery (p = 0.002), no prior radiotherapy (p = 0.025), smaller AVM nidus (p = 0.002), deep venous drainage (p = 0.039), and nidus location (p < 0.0001). Basal ganglia, cerebellum, and frontal lobe nidus locations favored early obliteration (p = 0.009). The Virginia Radiosurgery AVM Scale (VRAS) score was significantly different between the 2 responder groups (p = 0.039). The VRAS score was also shown to be predictive of early obliteration on univariate analysis (p = 0.009). For early obliteration, such prognostic ability was not shown for other SRS- and AVM-related grading systems.CONCLUSIONSEarly obliteration (≤ 18 months post-SRS) was more common in patients whose AVMs were smaller, located in the frontal lobe, basal ganglia, or cerebellum, had deep venous drainage, and had received a margin dose > 24 Gy.

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Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study

Journal of Neurosurgery ◽

10.3171/2018.8.jns182106 ◽

2020 ◽

Vol 132 (1) ◽

pp. 122-131

Author(s):

Ching-Jen Chen ◽

Kathryn N. Kearns ◽

Dale Ding ◽

Hideyuki Kano ◽

David Mathieu ◽

...

Keyword(s):

Basal Ganglia ◽

Stereotactic Radiosurgery ◽

Arteriovenous Malformations ◽

Radiation Effects ◽

Favorable Outcome ◽

Study Cohort ◽

Multicenter Cohort Study ◽

Radiation Induced ◽

The Mean ◽

International Multicenter Study

OBJECTIVEArteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects.METHODSThe authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome.RESULTSThe study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044).CONCLUSIONSSRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.

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BrainPath-Mediated Resection of a Ruptured Subcortical Arteriovenous Malformation

Operative Neurosurgery ◽

10.1093/ons/opx186 ◽

2017 ◽

Vol 15 (1) ◽

pp. 32-38 ◽

Cited By ~ 5

Author(s):

Alex M Witek ◽

Nina Z Moore ◽

M Adeeb Sebai ◽

Mark D Bain

Keyword(s):

Basal Ganglia ◽

Intracerebral Hemorrhage ◽

Arteriovenous Malformation ◽

Frontal Lobe ◽

Tubular Retractor ◽

Postoperative Imaging ◽

Hematoma Evacuation ◽

The Right

AbstractBACKGROUNDAlthough tubular retractor systems have gained popularity for other indications, there have been few reports of their use for arteriovenous malformation (AVM) surgery. A patient was diagnosed with a ruptured 1.2-cm subcortical AVM after presenting with intracerebral hemorrhage in the right frontal lobe and anterior basal ganglia. The characteristics of this AVM made it amenable to resection using a tubular retractor.OBJECTIVETo demonstrate the feasibility and safety of AVM resection using a tubular retractor system.METHODSResection of the ruptured 1.2-cm subcortical AVM was performed utilizing the BrainPathTM (NICO corp, Indianapolis, Indiana) tubular retractor system.RESULTSThe BrainPathTM approach provided sufficient visualization and surgical freedom to permit successful AVM resection and hematoma evacuation. Postoperative imaging demonstrated near total hematoma removal and angiographic obliteration of the AVM. There were no complications, and the patient made an excellent recovery.CONCLUSIONTubular retractors warrant consideration for accessing small, deep, ruptured AVMs. The nuances of such systems and their role in AVM surgery are discussed.

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Thoracic 11-Lumbar 1 Laminoplasty for Resection of Conus Arteriovenous Malformation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz305 ◽

2019 ◽

Vol 18 (1) ◽

pp. E7-E7

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Arteriovenous Malformation ◽

Video Recording ◽

Venous Drainage ◽

Conus Medullaris ◽

Imaging Evaluation ◽

Drainage Patterns ◽

Institutional Review ◽

Before And After ◽

Spinal Arteriovenous Malformations ◽

Multiple Feeding

Abstract Conus medullaris spinal arteriovenous malformations are uniquely classified by the Spetzler classification. They possess a glomus (type II) nidus in either or both the intra- and extramedullary compartments, with multiple feeding arteries and niduses resulting in complex venous drainage patterns. These characteristics make resection of these lesions challenging, and these lesions are associated with a high risk for recurrence. This patient presented with a subarachnoid hemorrhage, and thorough imaging evaluation revealed a conus arteriovenous malformation. The patient underwent thoracic 11 to lumbar 1 laminoplasty for resection of the lesion. The arteriovenous malformation was circumdissected off the conus and lumbosacral nerve roots using sharp dissection and bipolar forceps. It was visualized both before and after resection with indocyanine green fluoroscopy. The patient tolerated the procedure well, and postoperative angiography demonstrated complete resection. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Thalamic and Basal Ganglia Arteriovenous Malformations: Redefining “Inoperable”

Operative Neurosurgery ◽

10.1227/01.neu.0000320137.55446.db ◽

2008 ◽

Vol 63 (suppl_1) ◽

pp. ONS63-ONS68 ◽

Cited By ~ 2

Author(s):

Edward A.M. Duckworth ◽

Bradley Gross ◽

H. Hunt Batjer

Keyword(s):

Basal Ganglia ◽

Natural History ◽

Stereotactic Radiosurgery ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Venous Drainage ◽

Lesion Size ◽

Small Lesion ◽

History Of ◽

Microsurgical Techniques

Abstract Deep Arteriovenous Malformations of the basal ganglia and thalamus have an aggressive natural history and present a therapeutic challenge. More often than not, these lesions are deemed “inoperable” and are treated expectantly or with stereotactic radiosurgery. In some cases, clinical details combined with an opportune route of access dictate surgical resection. History of hemorrhage, small lesion size, and deep venous drainage each add to the aggressive natural history of these malformations. Interestingly, these same factors can point toward surgery. We present a discussion of the microsurgical techniques involved in managing these lesions, with an emphasis on situations that allow these lesions to be approached surgically.

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Resection of Right Frontal Arteriovenous Malformation: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy090 ◽

2018 ◽

Vol 16 (1) ◽

pp. 111-111

Author(s):

William T Couldwell

Keyword(s):

Arteriovenous Malformation ◽

Venous Drainage ◽

Complete Resection ◽

Institutional Review Board ◽

3 Dimensional ◽

Bone Removal ◽

Institutional Review ◽

Brain Interface ◽

Grade Ii ◽

The Right

Abstract The video demonstrates resection of a Grade II Spetzler-Martin unruptured, medium-sized arteriovenous malformation (AVM). A young woman presented with headaches and seizures. The right frontal lesion measured 4.5 cm in largest dimension and had superficial venous drainage. Partial Onyx embolization, primarily of the anterior cerebral feeding arteries, was performed. Bone removal for exposure allowed identification of indentation from the large superficial draining vein. The video demonstrates careful microsurgical dissection on the AVM/brain interface, with selective interruption of feeding arteries circumferentially. The lesion was removed after ligation of the large superficial draining vein. Postoperative day 1 and 1-yr angiography demonstrated complete resection. The patient's symptoms abated after resection. This case is presented with a waiver of informed consent as per the Institutional Review Board.

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Interhemispheric Transfalcine Approach for Resection of Contralateral Arteriovenous Malformation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa002 ◽

2020 ◽

Vol 18 (5) ◽

pp. E155-E156 ◽

Cited By ~ 1

Author(s):

Benjamin K Hendricks ◽

Robert F Spetzler

Keyword(s):

Informed Consent ◽

Arteriovenous Malformation ◽

Frontal Lobe ◽

Video Recording ◽

Complete Removal ◽

Institutional Review Board ◽

Ipsilateral Hemisphere ◽

Institutional Review Board Approval ◽

Interhemispheric Approach ◽

Institutional Review

Abstract The high versatility and efficacy of the contralateral interhemispheric approach is demonstrated in this resection of an arteriovenous malformation (AVM). This patient had a large AVM along the medial frontal lobe amenable to approach via the contralateral interhemispheric approach. The head was rotated to permit gravity retraction of the ipsilateral hemisphere to the AVM, avoiding the use of rigid retractors. Under the guidance of neuronavigation, the falx was opened to permit visualization of the AVM. Circumdissection with a disconnection of the nidus was performed in a standard fashion. Postoperative angiography confirmed complete removal of the AVM. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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Arterial-spin labeling MRI identifies residual cerebral arteriovenous malformation following stereotactic radiosurgery treatment

Journal of Neuroradiology ◽

10.1016/j.neurad.2018.12.004 ◽

2020 ◽

Vol 47 (1) ◽

pp. 13-19 ◽

Cited By ~ 3

Author(s):

Jeremy J. Heit ◽

Neil H. Thakur ◽

Michael Iv ◽

Nancy J. Fischbein ◽

Max Wintermark ◽

...

Keyword(s):

Arteriovenous Malformation ◽

Stereotactic Radiosurgery ◽

Arterial Spin Labeling ◽

Spin Labeling ◽

Cerebral Arteriovenous Malformation

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A case of delayed cyst formation post brain AVM stereotactic radiosurgery for arteriovenous malformation: Case report

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2021.01.051 ◽

2021 ◽

Vol 87 ◽

pp. 17-19

Author(s):

Arash Kahrom ◽

Rohan Grimley ◽

Rosalind L. Jeffree

Keyword(s):

Case Report ◽

Arteriovenous Malformation ◽

Stereotactic Radiosurgery ◽

Cyst Formation ◽

Brain Avm

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Stereotactic radiosurgery as the first-line treatment for intracanalicular vestibular schwannomas

Journal of Neurosurgery ◽

10.3171/2020.9.jns202818 ◽

2021 ◽

pp. 1-7

Author(s):

Akiyoshi Ogino ◽

L. Dade Lunsford ◽

Hao Long ◽

Stephen Johnson ◽

Andrew Faramand ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Observation Interval ◽

Univariate Analysis ◽

Hearing Preservation ◽

Vestibular Schwannomas ◽

Tumor Control ◽

Line Treatment ◽

First Line ◽

Additional Intervention ◽

First Line Treatment

OBJECTIVEThis report evaluates the outcomes of stereotactic radiosurgery (SRS) as the first-line treatment of intracanalicular vestibular schwannomas (VSs).METHODSBetween 1987 and 2017, the authors identified 209 patients who underwent SRS as the primary intervention for a unilateral intracanalicular VS. The median patient age was 54 years (range 22–85 years); 94 patients were male and 115 were female. Three patients had facial neuropathy at the time of SRS. One hundred fifty-five patients (74%) had serviceable hearing (Gardner-Robertson [GR] grades I and II) at the time of SRS. The median tumor volume was 0.17 cm3 (range 0.015–0.63 cm3). The median margin dose was 12.5 Gy (range 11.0–25.0 Gy). The median maximum dose was 24.0 Gy (range 15.7–50.0 Gy).RESULTSThe progression-free survival rates of all patients with intracanalicular VS were 97.5% at 3 years, 95.6% at 5 years, and 92.1% at 10 years. The rates of freedom from the need for any additional intervention were 99.4% at 3 years, 98.3% at 5 years, and 98.3% at 10 years. The serviceable hearing preservation rates in GR grade I and II patients at the time of SRS were 76.6% at 3 years, 63.5% at 5 years, and 27.3% at 10 years. In univariate analysis, younger age (< 55 years, p = 0.011), better initial hearing (GR grade I, p < 0.001), and smaller tumor volumes (< 0.14 cm3, p = 0.016) were significantly associated with improved hearing preservation. In multivariate analysis, better hearing (GR grade I, p = 0.001, HR 2.869, 95% CI 1.569–5.248) and smaller tumor volumes (< 0.14 cm3, p = 0.033, HR 2.071, 95% CI 1.059–4.047) at the time of SRS were significantly associated with improved hearing preservation. The hearing preservation rates of patients with GR grade I VS were 88.1% at 3 years, 77.9% at 5 years, and 38.1% at 10 years. The hearing preservation rates of patients with VSs smaller than 0.14 cm3 were 85.5% at 3 years, 77.7% at 5 years, and 42.6% at 10 years. Facial neuropathy developed in 1.4% from 6 to 156 months after SRS.CONCLUSIONSSRS provided sustained tumor control in more than 90% of patients with intracanalicular VS at 10 years and freedom from the need for additional intervention in more than 98% at 10 years. Patients with initially better hearing and smaller VSs had enhanced serviceable hearing preservation during an observation interval up to 10 years after SRS.

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