Radiosurgery as a microsurgical adjunct: outcomes after microsurgical resection of intracranial arteriovenous malformations previously treated with stereotactic radiosurgery

2021 ◽  
pp. 1-12
Author(s):  
Mark Bigder ◽  
Omar Choudhri ◽  
Mihir Gupta ◽  
Santosh Gummidipundi ◽  
Summer S. Han ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Perioperative Period ◽  
Low Grade ◽  
High Grade ◽  
Eligibility Criteria ◽  
Previously Treated ◽  
Microsurgical Resection ◽  
Cerebral Avms ◽  
Staged Treatment

OBJECTIVE Microsurgical resection of arteriovenous malformations (AVMs) can be aided by staged treatment consisting of stereotactic radiosurgery followed by resection in a delayed fashion. This approach is particularly useful for high Spetzler-Martin (SM) grade lesions because radiosurgery can reduce flow through the AVM, downgrade the SM rating, and induce histopathological changes that additively render the AVM more manageable for resection. The authors present their 28-year experience in managing AVMs with adjunctive radiosurgery followed by resection. METHODS The authors retrospectively reviewed records of patients treated for cerebral AVMs at their institution between January 1990 and August 2019. All patients who underwent stereotactic radiosurgery (with or without embolization), followed by resection, were included in the study. Of 1245 patients, 95 met the eligibility criteria. Univariate and multivariate regression analyses were performed to assess relationships between key variables and clinical outcomes. RESULTS The majority of lesions treated (53.9%) were high grade (SM grade IV–V), 31.5% were intermediate (SM grade III), and 16.6% were low grade (SM grade I–II). Hemorrhage was the initial presenting sign in half of all patients (49.5%). Complete resection was achieved among 84% of patients, whereas 16% had partial resection, the majority of whom received additional radiosurgery. Modified Rankin Scale (mRS) scores of 0–2 were achieved in 79.8% of patients, and 20.2% had poor (mRS scores 3–6) outcomes. Improved (44.8%) or stable (19%) mRS scores were observed among 63.8% of patients, whereas 36.2% had a decline in mRS scores. This includes 22 patients (23.4%) with AVM hemorrhage and 6 deaths (6.7%) outside the perioperative period but prior to AVM obliteration. CONCLUSIONS Stereotactic radiosurgery is a useful adjunct in the presurgical management of cerebral AVMs. Multimodal therapy allowed for high rates of AVM obliteration and acceptable morbidity rates, despite the predominance of high-grade lesions in this series of patients.

Abstract TMP118: Clinical Outcomes of Surgical Resection After Stereotactic Radiosurgery Among Patients With Cerebral Arteriovenous Malformations

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mark G Bigder ◽  
Omar Choudhri ◽  
Mihir Gupta ◽  
Ephraim Church ◽  
Steven Chang ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Perioperative Period ◽  
Multivariate Regression Analysis ◽  
Low Grade ◽  
High Grade ◽  
Eligibility Criteria ◽  
Cerebral Avms

Introduction: Surgical treatment of arteriovenous malformations (AVMs), particularly higher grade lesions, can be aided by staged treatment consisting of stereotactic radiosurgery (SRS) followed by surgical resection in a delayed fashion. This strategy can be used to downgrade the AVM S-M grade, reduce blood flow through the AVM and often results in histopathological changes making AVMs more amenable to microsurgical resection. We present our 28-year clinical experience in managing AVMs with pre-operative SRS as a surgical adjunct. Methods: We retrospectively reviewed and analyzed records of all patients treated for cerebral AVMs between February 1991 and July 2019 at our institution. All patients that underwent SRS, with and without embolization, followed by microsurgery were included in the study. Of the 1245 cerebral AVM patients treated at our institution, 62 patients met eligibility criteria. Univariate and multivariate regression analysis was performed where appropriate to examine relationships between key variables and outcomes. Results: The majority of lesions (50%) were high grade (SM 4-5), 28.6% were intermediate (SM 3), while 21.4% were low grade (SM 1-2). Hemorrhage was the presenting sign among 22.6% of patients. Complete resection was achieved among 64.5%, 79% and 82% of patients after first, second and third surgical stages respectively; 16.1% of patients had partial resection requiring further treatment. Radiographic cure was achieved among 53 patients (85.5%), while 8 (12.9%) patients had residual AVM at last follow up. Six of 8 patients without radiographic cure received post-operative SRS. Thirty-seven patients (63.8%) had improved (26, 44.8%) or stable mRS scores (11, 19%), while 21 (36.2%) had a decline in mRS at final follow up compared to mRS at presentation; this includes 4 (6.9%) deaths due to hemorrhage, outside of the perioperative period, but occurring during follow up prior to AVM obliteration. Conclusion: SRS is a useful adjunct in the surgical management of cerebral AVMs. Multimodal therapy allowed for high obliteration rates with acceptable morbidity in this series of patients with predominantly high grade AVMs.

Repeat stereotactic radiosurgery for high-grade and large intracranial arteriovenous malformations

2007 ◽  
Vol 68 (1) ◽  
pp. 24-34 ◽  
Author(s):  
Shaan M. Raza ◽  
Salma Jabbour ◽  
Quoc-Anh Thai ◽  
Gustavo Pradilla ◽  
Lawrence R. Kleinberg ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
High Grade ◽  
Intracranial Arteriovenous Malformations

Surgical Management Of Posterior Fossa Arteriovenous Malformations

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-189-ONS-201 ◽  
Author(s):  
John Sinclair ◽  
Michael E. Kelly ◽  
Gary K. Steinberg
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Cerebellar Nuclei ◽  
Preoperative Embolization ◽  
Frameless Stereotaxy ◽  
Microsurgical Resection

Abstract Objective: Arteriovenous malformations (AVMs) involving the cerebellum and brainstem are relatively rare lesions that most often present clinically as a result of a hemorrhagic episode. Although these AVMs were once thought to have a more aggressive clinical course in comparison with supratentorial AVMs, recent autopsy data suggests that there may be little difference in hemorrhage rates between the two locations. Although current management of these lesions often involves preoperative embolization and stereotactic radiosurgery, surgical resection remains the treatment of choice, conferring immediate protection to the patient from the risk of future hemorrhage. Methods: Most symptomatic AVMs that involve the cerebellum and the pial or ependymal surfaces of the brainstem are candidates for surgical resection. Preoperative angiography and magnetic resonance imaging studies are critical to determine suitability for resection and choice of operative exposure. In addition to considering the location of the nidus, arterial supply, and predominant venous drainage, the surgical approach must also be selected with consideration of the small confines of the posterior fossa and eloquence of the brainstem, cranial nerves, and deep cerebellar nuclei. Results: Since the 1980s, progressive advances in preoperative embolization, frameless stereotaxy, and intraoperative electrophysiologic monitoring have significantly improved the number of posterior fossa AVMs amenable to microsurgical resection with minimal morbidity and mortality. Conclusion: Future improvements in endovascular technology and stereotactic radiosurgery will likely continue to increase the number of posterior fossa AVMs that can safely be removed and further improve the clinical outcomes associated with microsurgical resection.

A multi-center, open-label study to evaluate the safety and efficacy of pentostatin, cytoxan, and rituxan (PCR) in the treatment of previously untreated or treated, stage III or IV, low-grade CLL

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 17508-17508
Author(s):  
R. R. Mena ◽  
R. Robles ◽  
M. Auerbach ◽  
M. Moezi ◽  
D. Headley
Keyword(s):  
Low Grade ◽  
Open Label ◽  
Eligibility Criteria ◽  
Bulky Disease ◽  
Clinical Evaluations ◽  
Treatment Naïve ◽  
Grade Ii ◽  
Previously Treated ◽  
Intent To Treat ◽  
Anti Cd20

17508 Background: The decision to treat indolent CLL is often based on progressive bulky disease, worsening symptoms, and increasing hematological variations. When treatment is indicated, these lymphoproliferative disorders are sensitive to combination immunochemotherapies utilizing pentostatin (P), a purine analog, cyclophosphamide (C), a DNA alkylator, and rituximab (R), an anti-CD20 monoclonal antibody. PCR represents a promising new approach in the treatment of patients with low grade CLL. Methods: Eligibility criteria allow previously treated and treatment-naïve patients diagnosed with low-grade stage II/III/IV CLL (modified Rai classification). Treatment consisted of intravenous infusions of P (4 mg/m2), C (600 mg/m2), and R (375 mg/m2) on day 1 of a 21-day cycle for a total of up to 10 cycles. Clinical evaluations (including CT scan) were performed after cycles 2, 4, 6, 8, and 10 (if necessary). Results: The intent-to-treat (ITT) population consisted of 80 CLL patients (median age 64, range 35–83) who received a total of 368 cycles (median 5 per patient). ECOG status at enrollment was 0 (68.4%), 1 (27.6%) and 2 (3.9%). The overall response rate of the 59 evaluable patients was 61% (CR 6.8%, Cru 16.9%, PR 37.3%). 7 cases of grade 4 neutropenia, 2 cases of grade 4 respiratory distress, and 1 case of grade 4 anemia were reported. 5 deaths, all in elderly patients (>70 years old), have been recorded, due to acute respiratory failure, myocardial infarction, pulmonary edema, sepsis, and one unknown cause of death. Conclusions: This immunochemotherapeutic regimen is active in Grade II/III/IV CLL and the incidence of significant toxicities was low with deaths occurring only in elderly (>80 YO) patients. The presented results are preliminary and this study is currently on-going. No significant financial relationships to disclose.

Sylvian Fissure Arteriovenous Malformations

Neurosurgery ◽  
2007 ◽  
Vol 61 (1) ◽  
pp. 29-38 ◽  
Author(s):  
Michael T. Lawton ◽  
Daniel C. Lu ◽  
William L. Young
Keyword(s):  
Patient Outcomes ◽  
Arteriovenous Malformations ◽  
Classification Scheme ◽  
Sylvian Fissure ◽  
Low Grade ◽  
Surgeon Experience ◽  
Scale Scores ◽  
Microsurgical Resection ◽  
Adjacent Brain

Abstract OBJECTIVE The Sugita classification for sylvian fissure arteriovenous malformations (AVMs) categorizes them into four types based on nidus location in the fissure: pure, lateral, medial, and deep. This classification scheme is simple and appealing, but is rarely applied. We applied the Sugita classification to a consecutive, single-surgeon experience with 28 patients to better characterize the Sugita subtypes. METHODS Twenty-eight patients with sylvian fissure AVMs were identified from a series of 314 AVM patients treated microsurgically over a 9-year period. According to the Sugita classification, six (21%) AVMs were pure, four (14%) were lateral, nine (32%) were medial, and nine (32%) were deep. Fifteen (54%) patients presented with hemorrhage. RESULTS There was no surgical mortality in this experience. Four (14%) patients had transient deterioration and one (3.6%) patient with a pure sylvian AVM was permanently worse. At late follow-up (mean duration, 20 mo), good outcomes (Modified Rankin Scale scores 0–2) were observed in 25 (89%) patients. CONCLUSION The Sugita classification does not modify the surgical approach or predict patient outcomes with sylvian fissure AVMs, but it does clarify anatomic differences between subtypes. These AVMs are a diverse group, with each subtype having unique relationships between arteries, veins, nidus, and adjacent brain that influence microsurgical technique. Despite their eloquent location and technical challenges, results with microsurgical resection are excellent, making this the preferred treatment option for low-grade AVMs.

Repeated linac-based radiosurgery in high-grade cerebral arteriovenous-malformations (AVM) Spetzler–Martin grade III to IV previously treated with radiosurgery

2011 ◽  
Vol 98 (2) ◽  
pp. 217-222 ◽  
Author(s):  
Henrik Hauswald ◽  
Stefanie Milker-Zabel ◽  
Florian Sterzing ◽  
Wolfgang Schlegel ◽  
Juergen Debus ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
High Grade ◽  
Cerebral Arteriovenous Malformations ◽  
Previously Treated ◽  
Martin Grade ◽  
Grade Iii

Long-term Outcomes With Planned Multistage Reduced Dose Repeat Stereotactic Radiosurgery for Treatment of Inoperable High-Grade Arteriovenous Malformations: An Observational Retrospective Cohort Study

Neurosurgery ◽  
2017 ◽  
Vol 81 (1) ◽  
pp. 136-146 ◽  
Author(s):  
Ariel E. Marciscano ◽  
Judy Huang ◽  
Rafael J. Tamargo ◽  
Chen Hu ◽  
Mohamed H. Khattab ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Median Number ◽  
Treatment Session ◽  
High Grade ◽  
Obliteration Rate ◽  
Long Term Study ◽  
Complete Obliteration

Abstract BACKGROUND: There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). OBJECTIVE: To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs. METHODS: Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected. RESULTS: Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated (P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year. CONCLUSION: Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.

scholarly journals Stereotactic Radiosurgery in the Management of Intracranial Gliomas

2003 ◽  
Vol 2 (2) ◽  
pp. 117-125 ◽  
Author(s):  
David Roberge ◽  
Luis Souhami
Keyword(s):  
Phase I ◽  
Stereotactic Radiosurgery ◽  
Primary Treatment ◽  
Current Data ◽  
Phase Iii ◽  
Low Grade ◽  
High Grade ◽  
Stereotactic Radiation ◽  
Select Group ◽  
High Grade Gliomas

Glial neoplasms are the most common primary intracranial malignancies. Treatment of high-grade gliomas has been frustrating, with less than 5% of patients surviving 5 years after a diagnosis of glioblastoma multiforme (GBM). Stereotactic radiosurgery (SRS) and fractionated strereotactic radiotherapy (F-SRT) provide means to either escalate the dose in primary treatment or to palliate recurrences. Because of their lower α/β ratios and more focal nature, low-grade gliomas (LGG) are more attractive targets for stereotactically focused radiation. Results of available phase I-II data are reviewed for both low and high-grade gliomas. In the case of high-grade gliomas disappointing preliminary phase III data from RTOG 93-05 are discussed. Toxicity of SRS is discussed. Acute treatment toxicity of significance is unusual and generally self-limited. Occasionally an exacerbation of existing symptoms occurs. Late complications attributable to SRS are usually defined as necrosis within the treatment volume. The rate of necrosis can be hard to define in high-grade gliomas as tumor cells are often present in surgical specimens. New strategies in the application of stereotactic radiation are touched upon, these include: changes in planning and fractionation, concurrent use of chemotherapy, use of radiation modifiers and biologic agents. After reviewing the current data for high-grade gliomas, it appears that any apparent improvement in outcome seen in phase I-II trials is attributable to patient selection. The best evidence available does not support the use of SRS for primary high-grade gliomas. The somewhat limited experience in LGG also indicates a lack of benefit for patients treated with stereotactic radiosurgery or F-SRT. For a very select group of patients with small recurrent lesions, F-SRT may represent a safe, reasonable treatment.

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