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.

scholarly journals International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery

2017 ◽  
Vol 19 (2) ◽  
pp. 136-148 ◽  
Author(s):  
Robert M. Starke ◽  
Dale Ding ◽  
Hideyuki Kano ◽  
David Mathieu ◽  
Paul P. Huang ◽  
...  
Keyword(s):  
Cohort Study ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Latency Period ◽  
Favorable Outcome ◽  
Brain Arteriovenous Malformations ◽  
Radiation Induced ◽  
The Mean ◽  
Induced Changes

OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8–17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5–35 Gy), and the mean follow-up was 92 months (range 12–266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.

scholarly journals Cyst formation after stereotactic radiosurgery for brain arteriovenous malformations: a systematic review

2018 ◽  
Vol 128 (5) ◽  
pp. 1354-1363 ◽  
Author(s):  
Adeel Ilyas ◽  
Ching-Jen Chen ◽  
Dale Ding ◽  
Panagiotis Mastorakos ◽  
Davis G. Taylor ◽  
...  
Keyword(s):  
Systematic Review ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Time Course ◽  
Surgical Intervention ◽  
Latency Period ◽  
Cyst Formation ◽  
Brain Arteriovenous Malformations ◽  
The Mean

OBJECTIVECyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs.METHODSA literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data.RESULTSBased on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years).CONCLUSIONSCyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.

scholarly journals In Reply: Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations

Neurosurgery ◽  
2017 ◽  
Vol 82 (3) ◽  
pp. E77-E78
Author(s):  
Adeel Ilyas ◽  
Ching-Jen Chen ◽  
Dale Ding ◽  
Thomas J Buell ◽  
Cheng-Chia Lee ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Radiation Induced ◽  
Induced Changes

Embolization of Brain Arteriovenous Malformations With Versus Without Onyx Before Stereotactic Radiosurgery

Neurosurgery ◽  
2020 ◽  
Author(s):  
Ching-Jen Chen ◽  
Dale Ding ◽  
Cheng-Chia Lee ◽  
Kathryn N Kearns ◽  
I Jonathan Pomeraniec ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
De Novo ◽  
Cyst Formation ◽  
Embolic Agent ◽  
Complication Rates ◽  
Ethylene Vinyl Alcohol ◽  
Brain Arteriovenous Malformations ◽  
Radiation Induced ◽  
Induced Changes

Abstract BACKGROUND Embolization of brain arteriovenous malformations (AVMs) using ethylene-vinyl alcohol copolymer (Onyx) embolization may influence the treatment effects of stereotactic radiosurgery (SRS) differently than other embolysates. OBJECTIVE To compare the outcomes of pre-SRS AVM embolization with vs without Onyx through a multicenter, retrospective matched cohort study. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Embolized AVMs treated with SRS were selected and categorized based on embolysate usage into Onyx embolization (OE + SRS) or non-Onyx embolization (NOE + SRS) cohorts. The 2 cohorts were matched in a 1:1 ratio using de novo AVM features for comparative analysis of outcomes. RESULTS The matched cohorts each comprised 45 patients. Crude AVM obliteration rates were similar between the matched OE + SRS vs NOE + SRS cohorts (47% vs 51%; odds ratio [OR] = 0.837, P = .673). Cumulative probabilities of obliteration were also similar between the OE + SRS vs NOE + SRS cohorts (subhazard ratio = 0.992, P = .980). Rates of post-SRS hemorrhage, all-cause mortality, radiation-induced changes, cyst formation, and embolization-associated complications were similar between the matched cohorts. Sensitivity analysis for AVMs in the OE + SRS cohort embolized with Onyx alone revealed a higher rate of asymptomatic embolization-associated complications in this subgroup compared to the NOE + SRS cohort (36% vs 15%; OR = 3.297, P = .034), but the symptomatic complication rates were similar. CONCLUSION Nidal embolization using Onyx does not appear to differentially impact the outcomes of AVM SRS compared with non-Onyx embolysates. The embolic agent selected for pre-SRS AVM embolization should reflect both the experience of the neurointerventionalist and target of endovascular intervention.

Abstract 127: Radiosurgery for Unruptured Intervention-Naïve Pediatric Brain Arteriovenous Malformations

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ching-jen Chen ◽  
Cheng-Chia Lee ◽  
Hideyuki Kano ◽  
Kathryn Kearns ◽  
Dale Ding ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Arteriovenous Malformations ◽  
Pediatric Population ◽  
Study Cohort ◽  
Brain Arteriovenous Malformations ◽  
History Of ◽  
Radiation Induced ◽  
Induced Changes ◽  
Pediatric Brain ◽  
Stroke Death

Background and Purpose: To evaluate, in a multicenter, retrospective cohort study, the outcomes after stereotactic radiosurgery (SRS) for unruptured, intervention-naïve pediatric brain arteriovenous malformations (AVM). Methods: We retrospectively analyzed the International Radiosurgery Research Foundation pediatric AVM database from 1987-2018. Pediatric patients with unruptured, previously untreated AVMs who underwent SRS were included. The primary endpoint was a composite of hemorrhagic stroke, death, or permanently symptomatic radiation-induced changes (RIC). Results: The study cohort comprised 101 patients (mean follow-up 80.8 months). The primary endpoint occurred in 14%, comprising hemorrhage stroke, death, and permanent RIC in 6%, 3%, and 8%, respectively. Estimated probabilities of the primary endpoint were 5.2%, 10.8%, and 23.0% at 2, 5, and 10 years, respectively (Figure 1). Estimated probabilities of AVM obliteration at 5 and 10 years were 64% and 82%, respectively (Figure 2). Single SRS treatment (p=0.007) and higher margin dose (p=0.005) were predictors of obliteration. Subgroup analysis of Spetzler-Martin grade I-III AVMs estimated primary endpoint probabilities of 3.7%, 8.4%, and 18.7% at 2, 5 and 10 years, respectively. Conclusion: Treatment of unruptured, intervention-naïve AVMs in the pediatric population with SRS carries an approximately 2% annual risk of morbidity and mortality, which appears to plateau after 10 years. The poorly described natural history of pediatric AVMs makes any comparison of SRS versus conservative management imperfect. However, due to the young age at diagnosis and excessive cumulative life hemorrhage risk of an untreated AVM in a child, SRS is likely to have a favorable long-term risk-benefit profile for appropriately selected unruptured pediatric AVMs.

Radiosurgery for Unruptured Intervention-Naïve Pediatric Brain Arteriovenous Malformations

Neurosurgery ◽  
2020 ◽  
Vol 87 (2) ◽  
pp. 368-376
Author(s):  
Ching-Jen Chen ◽  
Cheng-Chia Lee ◽  
Hideyuki Kano ◽  
Kathryn N Kearns ◽  
Dale Ding ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Arteriovenous Malformations ◽  
Hemorrhagic Stroke ◽  
Pediatric Population ◽  
Study Cohort ◽  
Brain Arteriovenous Malformations ◽  
Radiation Induced ◽  
Induced Changes ◽  
Pediatric Brain ◽  
Stroke Death

Abstract BACKGROUND Long-term data regarding stereotactic radiosurgery (SRS) as a standalone therapy for unruptured pediatric brain arteriovenous malformations (AVMs) are incompletely defined. OBJECTIVE To evaluate, in a multicenter, retrospective cohort study, the outcomes after SRS for unruptured, intervention-naïve pediatric AVMs. METHODS To retrospectively analyze the International Radiosurgery Research Foundation pediatric AVM database from 1987 to 2018. Pediatric patients with unruptured, previously untreated AVMs who underwent SRS were included. The primary endpoint was a composite of hemorrhagic stroke, death, or permanently symptomatic radiation-induced changes. RESULTS The study cohort comprised 101 patients (mean follow-up 80.8 mo). The primary endpoint occurred in 14%, comprising hemorrhagic stroke, death, and permanent radiation-induced changes in 6%, 3%, and 8%, respectively. Estimated probabilities of the primary endpoint were 5.2%, 10.8%, and 23.0% at 2, 5, and 10 yr, respectively. Estimated probabilities of AVM obliteration at 5 and 10 yr were 64% and 82%, respectively. Single SRS treatment (P = .007) and higher margin dose (P = .005) were predictors of obliteration. Subgroup analysis of Spetzler-Martin grade I-III AVMs estimated primary endpoint probabilities of 3.7%, 8.4%, and 18.7% at 2, 5, and 10 yr, respectively. CONCLUSION Treatment of unruptured, intervention-naïve AVMs in the pediatric population with SRS carries an approximately 2% annual risk of morbidity and mortality, which appears to plateau after 10 yr. The poorly described natural history of pediatric AVMs renders any comparison of SRS vs conservative management imperfect.

Sign in / Sign up

Export Citation Format

Share Document