scholarly journals Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiangyu Meng ◽  
Hongwei He ◽  
Peng Liu ◽  
Dezhi Gao ◽  
Yu Chen ◽  
...  
Keyword(s):  
Treatment Group ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Group Analysis ◽  
Gamma Knife Surgery ◽  
Treatment Modalities ◽  
Factors Associated ◽  
Obliteration Rate ◽  
Brain Arteriovenous Malformations

Background and purpose: To evaluate whether a radiosurgery-based arteriovenous malformation (AVM) scale (RBAS) could be used to predict obliteration of brain arteriovenous malformations (bAVMs) supposed for combined endovascular embolization (EMB) and gamma knife surgery (GKS) treatment.Methods: bAVM patients who underwent GKS with or without previous EMB from January 2011 to December 2016 at our institution were retrospectively reviewed. The patients were categorized into a combined treatment group and a GKS group. A 1:1 propensity score matching (PSM) was used to match the two groups. Pre-EMB and pre-GKS RBAS were assessed for every patient. Multivariate analysis was performed to find factors associated with complete obliteration in the combined treatment group. Survival analysis based on sub-groups according to RBAS was performed to compare obliteration rate and find cutoffs for appropriate treatment modalities.Results: A total of 96 patients were involved, and each group comprised 48 patients. There was no difference between the two groups in terms of obliteration rate (75.0 vs. 83.3%, p = 0.174). Pre-EMB RBAS (p = 0.010) and the number of feeding arteries (p = 0.014) were independent factors associated with obliteration rate in the combined treatment group. For the combined treatment patients, sub-group analysis according to pre-EMB RBAS (score <1.0, 1.0–1.5, and >1.5) showed statistical difference in obliteration rate (p = 0.002). Sub-group analysis according to RBAS between the two groups showed that the obliteration rate of the GKS group is significantly higher than the combined group when RBAS >1.5 (47.4 vs. 66.7%, p = 0.036).Conclusions: The RBAS is proposed to be efficient in predicting obliteration of bAVMs supposed to receive combined EMB and GKS treatment. Patients with RBAS >1.5 are inclined to be more suitable for GKS instead of the combined treatment.

Retrospective analysis of unstaged and staged Gamma Knife surgery with and without preceding embolization for the treatment of arteriovenous malformations

2008 ◽  
Vol 109 (Supplement) ◽  
pp. 57-64 ◽  
Author(s):  
Adam G. Back ◽  
Dennis Vollmer ◽  
Otto Zeck ◽  
Clive Shkedy ◽  
Peter M. Shedden
Keyword(s):  
Retrospective Study ◽  
Retrospective Analysis ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Surgery ◽  
Ct Scans ◽  
Treatment Modalities ◽  
Mr Images ◽  
Obliteration Rate

Object The authors conducted a retrospective study to examine data on rates of obliteration of arteriovenous malformations (AVMs) with use of various combinations of treatment modalities based on Gamma Knife surgery (GKS). The authors believe that this study is the first to report on patients treated with embolization followed by staged GKS. Methods The authors identified 150 patients who underwent GKS for treatment of AVMs between 1994 and 2004. In a retrospective study, 4 independent groups emerged based on the various combinations of treatment: 92 patients who underwent unstaged GKS, 28 patients who underwent embolization followed by unstaged GKS, 23 patients who underwent staged GKS, and 7 patients who underwent embolization followed by staged GKS. A minimum of 3 years of follow-up after the last GKS treatment was required for inclusion in the retrospective analysis. Angiograms, MR images, or CT scans at follow-up were required for calculating rates of obliteration of AVMs. Results Fifty-seven of 150 patients (38%) supplied angiograms, and overall obliteration was confirmed in 43 of these 57 patients (75.4%). An additional 37 patients had follow-up MR images or CT scans. The overall obliteration rate, including patients with follow-up angiograms and patients with follow-up MR images or CT scans, was 68 of 94 (72.3%). Patients who underwent unstaged GKS had a follow-up rate of 58.7% (54 of 92) and an obliteration rate of 75.9% (41 of 54). Patients who underwent embolization followed by unstaged GKS had a follow-up rate of 53.5% (15 of 28) and an obliteration rate of 60.0% (9 of 15). Patients who underwent staged GKS had a follow-up rate of 82.6% (19 of 23) and an obliteration rate of 73.7% (14 of 19). Patients who underwent embolization followed by staged GKS had a follow-up rate of 85.7% (6 of 7) and an obliteration rate of 66.7% (4 of 6). Conclusions Gamma Knife surgery is an effective means of treating AVMs. Embolization prior to GKS may reduce AVM obliteration rates. Staged GKS is a promising method for obtaining high obliteration rates when treating larger AVMs in eloquent locations.

Gamma Knife surgery for large cerebral arteriovenous malformations

2010 ◽  
Vol 113 (Special_Supplement) ◽  
pp. 2-8 ◽  
Author(s):  
Hae Yu Kim ◽  
Won Seok Chang ◽  
Dong Joon Kim ◽  
Jae Whan Lee ◽  
Jin Woo Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Lesion Size ◽  
Primary Treatment ◽  
Gamma Knife Surgery ◽  
Treatment Modalities ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
The Mean

Object Treatment of arteriovenous malformations (AVMs) is problematic due to many factors, including lesion size, lesion location, unacceptable complications, and negative outcomes. To overcome the limitation imposed by a large nidus volume, neurosurgeons have used Gamma Knife surgery (GKS) in a variety of ways, including combined with other treatment modalities, as volume-staged radiosurgery, and as repeat radiosurgery. We performed repeat radiosurgeries in patients who harbored large AVMs (> 30 cm3) and analyzed the AVM obliteration rates and complications. Methods The authors reviewed the cases of 44 patients at a single institution who underwent GKS between 1992 and 2007 for treatment of an AVM whose nidus was 30 cm3 or larger. The mean age of the patients was 27 years (range 4.5–62.3 years), and the median duration of follow-up was 109.4 months (range 27–202 months). The mean AVM nidus volume was 48.8 cm3 (range 30.3–109.5 cm3), and the mean radiation dose delivered to the margin of the nidus was 13.9 Gy (range 8.4–17.5 Gy). The authors determined complete AVM nidus obliteration based on findings on both MR images and digital subtraction angiograms. When they did not detect complete obliteration after GKS, they performed 1 or more additional GKSs separated by a minimum interval of 3 years. Results The overall obliteration rate following repeat GKS was 34.1%, and the estimated obliteration rate at 120 months was 41.8%. Three patients (6.8%) experienced hemorrhages after GKS, and 2 patients (4.5%) developed cysts. One patient (2.3%) experienced a newly developed seizure following GKS, and another patient (2.3%) was found to have radiation necrosis. Conclusions Even though complete obliteration of the large AVMs after repeat GKS took a long time, the complication rate was quite acceptable. In addition, the estimated obliteration rate at long-term follow-up was respectable. Repeat GKS should be considered as a primary treatment option for symptomatic large AVMs to overcome the limitation imposed on successful obliteration by the large volume of the nidus.

Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades

2019 ◽  
Vol 12 (4) ◽  
pp. 401-406
Author(s):  
Dorian Hirschmann ◽  
Philipp Goebl ◽  
Frederic H Witte ◽  
Brigitte Gatterbauer ◽  
Wei-Te Wang ◽  
...  
Keyword(s):  
Median Time ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Combined Therapy ◽  
Combined Treatment ◽  
Gamma Knife Radiosurgery ◽  
Effective Treatment Option ◽  
Obliteration Rate ◽  
Cerebral Avms ◽  
Modern Era

BackgroundGamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed.ObjectiveTo present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs.MethodsOverall, 516 patients received radiosurgery for cerebral AVMs between 1992 and 2018 at our department, of whom 265 received radiosurgery alone and 207 were treated with a combined endovascular-radiosurgical approach. Moreover, 45 patients were treated with a volume-staged approach. Two eras were analyzed, the pre-modern era between 1992 and 2002 and the modern era thereafter.ResultsIn GKRS-only treated patients, median time to nidus occlusion was 3.8 years. Spetzler–Ponce (SP) class was a significant predictor for time to obliteration in the whole sample. Median time to obliteration for the combined treatment group was 6.5 years. Patients in the pre-modern era had a significantly higher obliteration rate than those treated in the modern era. Overall, the calculated yearly hemorrhage risk in the observation period after first GKRS was 1.3%. Permanent post-radiosurgical complications occurred in 4.9% of cases but did not differ between the treatment groups or treatment eras. The obliteration rate was significantly lower and the hemorrhage rate was higher in volume-staged treated patients than in conventionally treated patients.ConclusionGKRS is an effective treatment option for SP class A and B cerebral AVMs. After combined endovascular-radiosurgical treatment, the outcome of selected SP class C AVMs aligns with that of SP class B lesions. Both the combined therapy and radiosurgery alone constitute sound methods for treatment of cerebral AVMs.

Long-term Results of Gamma Knife Surgery for Partially Embolized Arteriovenous Malformations

Neurosurgery ◽  
2012 ◽  
Vol 71 (6) ◽  
pp. 1139-1148 ◽  
Author(s):  
Lucia Schwyzer ◽  
Chun-Po Yen ◽  
Avery Evans ◽  
Sebastian Zavoian ◽  
Ladislau Steiner
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Gamma Knife Surgery ◽  
Long Term Results ◽  
Historical Series ◽  
Radiation Induced ◽  
The Mean ◽  
Induced Changes

ABSTRACT BACKGROUND: The effectiveness and risk of Gamma Knife surgery (GKS) in the management of partially embolized cerebral arteriovenous malformations (AVMs) remain to be elucidated. OBJECTIVE: To evaluate the long-term imaging and clinical outcomes of GKS in AVM patients who had undergone previous partial embolization and compare the results with patients treated with GKS alone. METHODS: A total of 215 embolized AVMs were analyzed. The mean patient age was 32.9 years. The mean volume of the nidus was 4.6 mL (range, 0.1-29.4 mL), and the mean prescription dose was 19.6 Gy (range, 4-28 Gy). This group was compared with 729 nonembolized AVMs. RESULTS: After embolization and GKS, angiographically confirmed total obliteration of the AVMs was significantly lower (33%) compared with patients in whom GKS was used alone (60.9%; P < .001). However, the mean nidus size was larger and the Spetzler-Martin grade was higher for the embolized AVMs compared with the nonembolized AVMs. Radiation-induced changes occurred more often in the embolized (43.4%) than the nonembolized (33.4%) AVMs (P = .028). Permanent neurological deficits associated with radiation-induced changes occurred in 2.7% of the embolized compared with 1.3% of the nonembolized patients (P = .14). CONCLUSION: In our retrospective and historical series, the long-term results suggest that the obliteration rate is significantly lower in embolized AVMs compared with nonembolized AVMs, also because of the fact that the combined treatment is applied to higher grade AVMs; the percentage of grade III-V AVMs was 58.6% and 48.8% for nonembolized AVMs.

Treatment of arteriovenous malformations with linear accelerator–based radiosurgery compared with Gamma Knife surgery

2006 ◽  
Vol 105 (Supplement) ◽  
pp. 58-63 ◽  
Author(s):  
Peter Orio ◽  
Keith J. Stelzer ◽  
Robert Goodkin ◽  
James G. Douglas
Keyword(s):  
Ct Angiography ◽  
Gamma Knife ◽  
Linear Accelerator ◽  
Arteriovenous Malformations ◽  
Mr Angiography ◽  
Gamma Knife Surgery ◽  
Median Dose ◽  
Obliteration Rate ◽  
Linac Radiosurgery

ObjectThe authors sought to compare the outcomes of patients with arteriovenous malformations (AVMs) treated by Gamma Knife surgery (GKS) with those of patients treated by linear accelerator–based (LINAC) radiosurgery.MethodsOne hundred and eighty-seven patients with AVMs were treated at our institution between 1992 and 2003. Ninety-one patients were treated with GKS and 96 patients were treated with LINAC radiosurgery. Patient and treatment characteristics in the two groups included the following. In the LINAC group, the median age was 33 years (range 9–66 years); the median dose was 16 Gy (70% isodose line); the median treated AVM volume was 5.5 cm3; and 46% of patients in this group were treated after hemorrhage. In the GKS group, the median age was 38 years (range 6–63 years); the median dose was 20 Gy (50% isodose line); the median treated AVM volume was 4.3 cm3; and 44% of patients in this group were treated after hemorrhage. Obliteration of AVMs was determined by performing computed tomography (CT) angiography and/or magnetic resonance (MR) angiography and angiography. Patient follow-up evaluation included obtaining an MR angiogram/MR image or CT angiogram at 6 months, at 1 year, and then annually thereafter. Angiography was performed to confirm obliteration when MR angiography and/or CT angiography no longer revealed evidence of an AVM.The 5-year estimated AVM obliteration rate was 66% in the entire patient group; the LINAC group was 60%; the GKS group was 72%; this difference was not statistically significant (p = 0.97). Twelve patients who underwent treatment with LINAC radiosurgery underwent retreatment with GKS and one was retreated with LINAC radiosurgery. The obliteration rate was 82%. Six patients treated with GKS were retreated with GKS, but the follow-up time is of short duration. Chronic toxicity occurred in 8% of both the GKS and the LINAC groups (p = 0.61). Posttreatment hemorrhage during the time of risk before AVM obliteration was 13% in the GKS group and 6.2% in the LINAC group (p = 0.05).Conclusions Treatment of patients with AVMs by using LINAC radiosurgery and GKS treatment produces high obliteration rates with acceptable long-term radiation toxicity in the patients treated.

Optimal timing for Gamma Knife surgery after hemorrhage from brain arteriovenous malformations

2008 ◽  
Vol 109 (Supplement) ◽  
pp. 73-76 ◽  
Author(s):  
Keisuke Maruyama ◽  
Tomoyuki Koga ◽  
Masahiro Shin ◽  
Hiroshi Igaki ◽  
Masao Tago ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Surgery ◽  
Neurological Deficits ◽  
Optimal Timing ◽  
Complication Rates ◽  
Brain Arteriovenous Malformations ◽  
Hemorrhagic Risk ◽  
Group 3 ◽  
Group 1

Object Optimal timing of Gamma Knife surgery (GKS) after hemorrhage from brain arteriovenous malformations (AVMs) is unclear and of concern to neurosurgeons because GKS is usually performed after absorption of the hematoma. The authors investigated whether waiting for hematoma absorption is beneficial and aimed to clarify the optimal treatment timing. Methods The authors retrospectively studied 211 patients with AVMs who presented with hemorrhage and underwent GKS as the initial treatment. Patients were categorized into 3 groups according to the interval between the time of first hemorrhage and GKS, as follows: Group 1, 0–3 months (70 patients); Group 2, 3–6 months (62 patients); and Group 3, > 6 months (79 patients). The obliteration rates, number of hemorrhages before and after GKS, and complication rates were compared between these 3 groups. The authors also analyzed a subgroup of 127 patients who presented with intracerebral hemorrhage (ICH) to identify the influence of ICH on outcome. Results After a median follow-up of 6.3 years, the rates of obliteration, hemorrhage after treatment, and complication were not significantly different between the 3 groups even though the patients with a longer interval before GKS (Group 3) had more AVMs in eloquent areas and neurological deficits. However, the numbers of patients with preoperative hemorrhage in the interval before GKS was significantly higher in Group 3 (1, 3, and 20 patients in Group 1, 2, and 3, respectively). These results were similar in the analyses of 127 patients presenting with ICH. Conclusions No benefit was detected in waiting for hematoma absorption until GKS after hemorrhage from AVM. Because of higher hemorrhagic risk until GKS > 6 months after hemorrhage, the authors recommend GKS within 6 months after hemorrhage.

scholarly journals Fistula components of brain arteriovenous malformations: Angioarchitecture analysis and embolization prior to gamma-knife surgery

2013 ◽  
Vol 76 (5) ◽  
pp. 277-281 ◽  
Author(s):  
Chao-Bao Luo ◽  
Wan-Yuo Guo ◽  
Michael Mu-Huo Teng ◽  
Feng-Chi Chang ◽  
Chung-Jung Lin ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Surgery ◽  
Brain Arteriovenous Malformations

Treatment of arteriovenous malformations using Gamma Knife surgery: the experience at the University of Washington from 2000 to 2005

2008 ◽  
Vol 109 (Supplement) ◽  
pp. 51-56 ◽  
Author(s):  
James G. Douglas ◽  
Robert Goodkin
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Medical Center ◽  
Gamma Knife Surgery ◽  
University Of Washington ◽  
Entire Cohort ◽  
Obliteration Rate ◽  
Kaplan Meier ◽  
The University ◽  
Male To Female

Object The purpose of this study was to examine the efficacy and toxicity of treating arteriovenous malformations (AVMs) with the model 3C Gamma Knife at the University of Washington Medical Center. Methods Ninety-five evaluable patients with 99 treatable AVMs were treated at the University of Washington Medical Center from April 2000 through June 2005. The median patient age at the time of treatment was 40 years (range 6–68 years). The male to female patient ratio was 0.98:1. The median AVM volume treated was 3.8 cm3 (range 0.12–32 cm3). Forty-four percent of the patients had hemorrhaged prior to treatment. The median peripheral Gamma Knife surgery dose was 20 Gy with a median of 12 isocenters treated. The median follow-up duration was 38 months (range 3–91 months). Eighty-one percent of the patients had no previous stereotactic radiosurgery (SRS), whereas the remaining 19% had previously been treated with linear accelerator–based SRS. Results The Kaplan–Meier estimated 6-year AVM obliteration rate for the entire cohort was 71.4%. The Kaplan–Meier estimated 6-year obliteration rate was 72% for patients having no prior SRS and 54.5% for those undergoing repeat SRS. The median time to AVM obliteration was 47 months, with 90% of the obliterations occurring between 24 and 58 months. Eight patients (7.4%) experienced late toxicities. There were 2 fatal bleeds and 13 (13.8%) nonfatal bleeds after Gamma Knife surgery. Conclusions Gamma Knife surgery is an effective treatment for AVMs, resulting in an excellent obliteration rate with acceptable toxicity.

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.

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