scholarly journals Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series

2021 ◽  
Vol 1 (25) ◽  
Author(s):  
Atsushi Shimizu ◽  
Koji Yamaguchi ◽  
Yoshikazu Okada ◽  
Takayuki Funatsu ◽  
Tatsuya Ishikawa ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
First Line Therapy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Before And After ◽  
Complete Obliteration

BACKGROUND Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS. OBSERVATIONS Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients. LESSONS This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.

Interim report on the radiosurgical treatment of cerebral arteriovenous malformations

1995 ◽  
Vol 83 (5) ◽  
pp. 832-837 ◽  
Author(s):  
Yoshihiro Yamamoto ◽  
Robert J. Coffey ◽  
Douglas A. Nichols ◽  
Edward G. Shaw
Keyword(s):  
Arteriovenous Malformations ◽  
Time Course ◽  
Gamma Knife Radiosurgery ◽  
Average Diameter ◽  
Neurological Deficits ◽  
Direct Result ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Complete Obliteration ◽  
Fine Print

✓ During the authors' initial 4-year experience with radiosurgery using the Leksell cobalt-60 gamma unit, they treated 121 patients with cerebral arteriovenous malformations (AVMs). The radiosurgical dose to the margin of the nidus was 20 Gy for lesions less than 2.0 cm in diameter (volume ≤ 4.2 cm3); 18 Gy for malformations 2.1 to 3.0 cm in diameter (volume 4.2–14.1 cm3); and 16 Gy for malformations greater than 3.0 cm (volume > 14.1 cm3). Fifty-one patients underwent follow-up angiography between 1 and 3 years after treatment, and complete obliteration of the nidus was confirmed in 38 (74.5%) of these patients. Thirty-two (74.4%) of 43 AVMs with volumes of 10 cm3 or less and six (75%) of eight larger AVMs (volume 11–30 cm3) showed complete obliteration. Analysis of the time course of AVM nidus shrinkage and obliteration showed that most of the radiosurgically induced effect had occurred by 36 months after treatment. Retrospective analysis of the dose plans for 10 AVMs that were not obliterated by 36 months after gamma knife radiosurgery at the authors' institution (eight cases) or elsewhere (two cases) revealed that six AVMs had not been covered completely by the prescribed isodose. Six (5%) of the 121 patients developed neurological deficits as a direct result of radiosurgical treatment. The authors infer from these data that malformations up to 30 cm3 in volume (approximately 4.0 cm in average diameter) can be treated effectively with an acceptably low complication rate using a radiosurgical dose of 16 Gy to the margin of the nidus. The obliteration rate for the larger malformations that were treated with a dose of 16 to 18 Gy appears to be similar to that for smaller ones treated with 18 to 20 Gy. As more experience accrues using radiosurgery to treat AVMs, patient selection criteria and the variables associated with successful obliteration of the nidus should become more clearly defined.

Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 113-119 ◽  
Author(s):  
D. Hung-Chi Pan ◽  
Wan-Yuo Guo ◽  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Yue-Cune Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Treatment ◽  
Gamma Knife Radiosurgery ◽  
Consecutive Series ◽  
Content Type ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
Fine Print

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

scholarly journals P03.08 Large cerebral arteriovenous malformations management with Volume-staged gamma knife radiosurgery

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii26-iii26
Author(s):  
R M Emad Eldin ◽  
W A Reda ◽  
A M El-Shehaby ◽  
K Abdel Karim ◽  
A Nabeel ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations ◽  
Factors Affecting ◽  
Prescription Dose ◽  
The Mean ◽  
Cerebral Avms ◽  
Grade 3

Abstract BACKGROUND Large cerebral arteriovenous malformations (AVM) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged gamma knife radiosurgery (VSGR) has been developed for the treatment of large AVMs, to increase the efficacy and improve safety of treatment of these lesions. The aim of the study was to assess the efficacy and safety of VSGR technique for the treatment of large cerebral AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All cases had large AVMs (>10 cc). These were 29 patients. RESULTS Twenty-four patients completed radiographic follow up with 15 obliteration cases (62.5%). There was a total of 56 sessions performed. The mean AVM volume was 16 cc (10.1–29.3 cc). The mean prescription dose was 18 Gy (14–22 Gy). The mean follow up duration was 43 months (21–73 months). One patient died during follow up from unrelated cause. Two cases suffered haemorrhage during follow up. Symptomatic edema developed in 5 (17%) patients. The factors affecting obliteration were smaller total volume, higher dose/stage, non-deep location, compact AVM, AVM score less than 3, >18 Gy dose and <15 cc total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (p 0.012). T2 image changes were affected by SM grade 3 or more (p 0.013) and AVM score 3 or more (p 0.014). CONCLUSION VSGR provides an effective and safe treatment option for large cerebral AVMs. Smaller AVM volume is associated with higher obliteration rate.

Gamma Knife Radiosurgery for the Treatment of Cavernous Sinus Meningiomas

Neurosurgery ◽  
2003 ◽  
Vol 52 (3) ◽  
pp. 517-524 ◽  
Author(s):  
Yoshiyasu Iwai ◽  
Kazuhiro Yamanaka ◽  
Tomoya Ishiguro
Keyword(s):  
Tumor Growth ◽  
Gamma Knife ◽  
Cavernous Sinus ◽  
Tumor Regression ◽  
Gamma Knife Radiosurgery ◽  
Growth Control ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Tumor Diameter

Abstract OBJECTIVE We report on the efficacy of gamma knife radiosurgery for cavernous sinus meningiomas. METHODS Between January 1994 and December 1999, we used gamma knife radiosurgery for the treatment of 43 patients with cavernous sinus meningiomas. Forty-two patients were followed up for a mean of 49.4 months (range, 18–84 mo). The patients' average age was 55 years (range, 18–81 yr). Twenty-two patients (52%) underwent operations before radiosurgery, and 20 patients (48%) underwent radiosurgery after the diagnosis was made by magnetic resonance imaging. The tumor volumes ranged from 1.2 to 101.5 cm3 (mean, 14.7 cm3). The tumors either compressed or were attached to the optic apparatus in 17 patients (40.5%). The marginal radiation dose was 8 to 15 Gy (mean, 11 Gy), and the optic apparatus was irradiated with 2 to 12 Gy (mean, 6.2 Gy). Three patients with a mean tumor diameter greater than 4 cm were treated by two-stage radiosurgery. RESULTS Thirty-eight patients (90.5%) demonstrated tumor growth control during the follow-up period after radiosurgery. Tumor regression was observed in 25 patients (59.5%), and growth was unchanged in 13 patients (31%). Regrowth or recurrence occurred in four patients (9.5%). The actual tumor growth control rate at 5 years was 92%. Only one patient (2.4%) experienced regrowth within the treatment field; in other patients, regrowth occurred at sites peripheral to or outside the treatment field. Twelve patients (28.6%) had improved clinically by the time of the follow-up examination. None of the patients experienced optic neuropathy caused by radiation injury or any new neurological deficits after radiosurgery. CONCLUSION Gamma knife radiosurgery may be a useful option for the treatment of cavernous sinus meningiomas not only as an adjuvant to surgery but also as an alternative to surgical removal. We have shown it to be safe and effective even in tumors that adhere to or are in close proximity to the optic apparatus.

scholarly journals A quantitative analysis of adverse radiation effects following Gamma Knife radiosurgery for arteriovenous malformations

2015 ◽  
Vol 123 (4) ◽  
pp. 945-953 ◽  
Author(s):  
Or Cohen-Inbar ◽  
Cheng-Chia Lee ◽  
Zhiyuan Xu ◽  
David Schlesinger ◽  
Jason P. Sheehan
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Effects ◽  
Late Onset ◽  
Gamma Knife Radiosurgery ◽  
Volumetric Analysis ◽  
Institutional Review ◽  
Complete Obliteration ◽  
Quantitative Changes

OBJECT The authors review outcomes following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs) and their correlation to postradiosurgery adverse radiation effects (AREs). METHODS From a prospective institutional review board–approved database, the authors identified patients with a minimum of 2 years of follow-up and thin-slice T2-weighted MRI sequences for volumetric analysis. A total of 105 AVM patients were included. The authors analyzed the incidence and quantitative changes in AREs as a function of time after GKRS. Statistical analysis was performed to identify factors related to ARE development and changes in the ARE index. RESULTS The median clinical follow-up was 53.8 months (range 24–212.4 months), and the median MRI follow-up was 36.8 months (range 24–212.4 months). 47.6% of patients had an AVM with a Spetzler-Martin grade ≥ III. The median administered margin and maximum doses were 22 and 40 Gy, respectively. The overall obliteration rate was 70.5%. Of patients who showed complete obliteration, 74.4% developed AREs within 4–6 months after GKRS. Late-onset AREs (i.e., > 12 months) correlated to a failure to obliterate the nidus. 58.1% of patients who developed appreciable AREs (defined as ARE index > 8) proceeded to have a complete nidus obliteration. Appreciable AREs were found to be influenced by AVM nidus volume > 3 ml, lobar location, number of draining veins and feeding arteries, prior embolization, and higher margin dose. On the other hand, a minimum ARE index > 8 predicted obliteration (p = 0.043). CONCLUSIONS ARE development after radiosurgery follows a temporal pattern peaking at 7–12 months after stereotactic radiosurgery. The ARE index serves as an important adjunct tool in patient follow-up and outcome prediction.

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 Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

1999 ◽  
Vol 27 (4) ◽  
pp. 241-247 ◽  
Author(s):  
Masaaki YAMAMOTO ◽  
Takayuki TANAKA ◽  
Nagatoshi BOKU ◽  
Seiji FUKUOKA ◽  
Hiromichi HOSODA ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations

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.

Combined Embolization and Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

1993 ◽  
Vol 34 (6) ◽  
pp. 600-606 ◽  
Author(s):  
W. Y. Guo ◽  
G. Wikholm ◽  
B. Karlsson ◽  
C. Lindquist ◽  
P. Svendsen ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Time Lag ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations ◽  
Neurologic Deficits ◽  
Feeding Vessels ◽  
Grade Iii

In a study of 46 patients with cerebral arteriovenous malformations (AVMs) the value of combining embolization and gamma knife radiosurgery was assessed. In 35 patients with large grade III to V AVMs (Spetzler-Martin system) staged combined treatment was planned. In 11 patients, radiosurgery complemented embolization for a residual AVM. The number of embolization sessions ranged from 1 to 7 (median 2). Twenty-six patients needed multiple embolization sessions. In 28 patients the grade of AVMs decreased as a result of embolization. In 16 patients collateral feeding vessels developed after embolization which made delineation of the residual nidus difficult. The time lag between the last embolization and radiosurgery ranged from 1 to 24 months (median 4). Nineteen of 35 large grade III to V AVMs were possible to treat by radiosurgery following embolization. In the 46 patients complications occurred in 9 from embolization and in 2 from radiosurgery. Two patients had transient and 9 had permanent neurologic deficits. It is concluded that embolization facilitates radiosurgery for some large AVMs and therefore this combined treatment has a role in the management of AVMs.

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