Short Term Effectiveness of Gamma Knife Radiosurgery in the Management of Brain Arteriovenous Malformation

AIM: To evaluate the short-term effectiveness of Gamma knife radiosurgery as a modality of treatment of brain arteriovenous malformation. METHODS: Sixty-three patients with arteriovenous brain malformations underwent Gamma knife radiosurgery included in this prospective study between April 2017 and September 2018 with clinical and radiological with MRI follow up was done at three months and six months post-Gamma knife radiosurgery. By the end of the 12th-month post-Gamma knife radiosurgery, the patients were re-evaluated using digital subtraction angiography co-registered with M.R.I. During the 12 months follow up, CT scan or MRI was done at any time if any one of the patients᾽ condition deteriorated or developed signs and symptoms of complications. The mean volume of the arteriovenous malformations treated was 26.0 ± 5 cm3 (range 12.5–39.5 cm3) in The Neurosciences Hospital, Baghdad/Iraq. RESULTS: By the end of the 12th month of follow up, the overall obliteration of the arteriovenous malformations was seen in six patients only (9.5%), while shrinkage was noticed in 57 patients (90.5%). Improvement or clinical stability was found in 24 out of 39 patients (61.5%) presented with epilepsy as a chief complaint before Gamma knife radiosurgery and 21 out of 24 patients (87.0%) complained of a headache before Gamma knife radiosurgery. Post-Gamma knife radiosurgery bleeding was found in only three patients (5.0%). CONCLUSION: Even with the short term follow up, Gamma knife radiosurgery has an excellent clinical outcome in most patients with arteriovenous brain malformations. The clinical symptoms like headache and seizure were either diminished or controlled with the same medical treatment dose before Gamma knife radiosurgery. Long term clinical and radiological follow up is recommended.

Download Full-text

Treatment Outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformation-Eligible Unruptured Brain Arteriovenous Malformation Patients

Neurosurgery ◽

10.1093/neuros/nyx506 ◽

2017 ◽

Vol 83 (3) ◽

pp. 548-555 ◽

Cited By ~ 10

Author(s):

Min Lang ◽

Nina Z Moore ◽

Peter A Rasmussen ◽

Mark D Bain

Keyword(s):

Arteriovenous Malformation ◽

Randomized Trial ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Interventional Treatment ◽

Brain Arteriovenous Malformation ◽

Brain Arteriovenous Malformations ◽

Number Of Patients ◽

Overall Risk

Abstract BACKGROUND The guideline for treating unruptured brain arteriovenous malformations (ubAVMs) remains controversial. A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) reported lower risk of stroke or death with conservative management compared to interventional treatment. There were numerous limitations to the study, including short follow-up period and disproportionate number of patients treated with surgery and embolization. OBJECTIVE To evaluate whether treatment of ARUBA-eligible patients have acceptable outcomes at our institution. METHODS Retrospective analysis was performed on 673 patients with brain AVMs treated at our institution between 2001 and 2014. One hundred five patients were ARUBA eligible and included in the study. Patients were divided into the microsurgery or Gamma Knife Radiosurgery (GKS; Elekta, Stockholm, Sweden) arm depending on their final treatment. Mean follow-up period was 43 mo (range 4-136 mo). Primary outcome was stroke or death. RESULTS A total of 8 (7.6%) patients had a stroke or died. The overall risk of stroke or death was 11.4% (5 of 44 patients) for the microsurgery arm and 4.9% (3 of 61 patients) for the GKS arm. The annual rates of stroke or death were 2.1%, 4.0%, and 1.2% for the entire patient cohort, microsurgery arm, and GKS arm, respectively. AVM obliteration rates at the end of the follow-up period were 95.5% and 47.5% for the microsurgery and GKS arms, respectively. CONCLUSION We report a lower overall risk of stroke or death in our ARUBA-eligible patients following treatment than ARUBA. Our results suggest that microsurgery and GKS may be appropriate treatments for patients with ubAVM.

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0113 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 113-119 ◽

Cited By ~ 82

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.

Download Full-text

Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0096 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 96-101 ◽

Cited By ~ 67

Author(s):

Jong Hee Chang ◽

Jin Woo Chang ◽

Yong Gou Park ◽

Sang Sup Chung

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Maximum Diameter ◽

Content Type ◽

Complete Occlusion ◽

Factors Associated ◽

Martin Grade ◽

Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

Download Full-text

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

Neuro-Oncology ◽

10.1093/neuonc/noz126.089 ◽

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.

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/2014.10.jns142264 ◽

2015 ◽

Vol 123 (4) ◽

pp. 945-953 ◽

Cited By ~ 12

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.

Download Full-text

Volumetric changes and clinical outcome for petroclival meningiomas after primary treatment with Gamma Knife radiosurgery

Journal of Neurosurgery ◽

10.3171/2017.7.jns17380 ◽

2018 ◽

Vol 129 (6) ◽

pp. 1623-1629 ◽

Cited By ~ 3

Author(s):

Zjiwar H. A. Sadik ◽

Suan Te Lie ◽

Sieger Leenstra ◽

Patrick E. J. Hanssens

Keyword(s):

Gamma Knife ◽

Clinical Symptoms ◽

Cranial Nerves ◽

Gamma Knife Radiosurgery ◽

Local Tumor Control ◽

Tumor Control ◽

Local Tumor ◽

Tumor Control Rate ◽

Petroclival Meningiomas

OBJECTIVEPetroclival meningiomas (PCMs) can cause devastating clinical symptoms due to mass effect on cranial nerves (CNs); thus, patients harboring these tumors need treatment. Many neurosurgeons advocate for microsurgery because removal of the tumor can provide relief or result in symptom disappearance. Gamma Knife radiosurgery (GKRS) is often an alternative for surgery because it can cause tumor shrinkage with improvement of symptoms. This study evaluates qualitative volumetric changes of PCM after primary GKRS and its impact on clinical symptoms.METHODSThe authors performed a retrospective study of patients with PCM who underwent primary GKRS between 2003 and 2015 at the Gamma Knife Center of the Elisabeth-Tweesteden Hospital in Tilburg, the Netherlands. This study yields 53 patients. In this study the authors concentrate on qualitative volumetric tumor changes, local tumor control rate, and the effect of the treatment on trigeminal neuralgia (TN).RESULTSLocal tumor control was 98% at 5 years and 93% at 7 years (Kaplan-Meier estimates). More than 90% of the tumors showed regression in volume during the first 5 years. The mean volumetric tumor decrease was 21.2%, 27.1%, and 31% at 1, 3, and 6 years of follow-up, respectively. Improvement in TN was achieved in 61%, 67%, and 70% of the cases at 1, 2, and 3 years of follow-up, respectively. This was associated with a mean volumetric tumor decrease of 25% at the 1-year follow-up to 32% at the 3-year follow-up.CONCLUSIONSGKRS for PCMs yields a high tumor control rate with a low incidence of neurological deficits. Many patients with TN due to PCM experienced improvement in TN after radiosurgery. GKRS achieves significant volumetric tumor decrease in the first years of follow-up and thereafter.

Download Full-text

Angiographic Long-term Follow-up Data for Arteriovenous Malformations Previously Proven to Be Obliterated after Gamma Knife Radiosurgery

Neurosurgery ◽

10.1097/00006123-200004000-00006 ◽

2000 ◽

Vol 46 (4) ◽

pp. 803-810 ◽

Cited By ~ 17

Author(s):

Melker Lindqvist ◽

Bengt Karlsson ◽

Wan-Yuo Guo ◽

Lars Kihlström ◽

Bodo Lippitz ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Long Term Follow Up

Download Full-text

Endovascular Treatment Accounts for a Change in Brain Arteriovenous Malformation Natural History Risk

Interventional Neuroradiology ◽

10.1177/159101991001600203 ◽

2010 ◽

Vol 16 (2) ◽

pp. 127-132 ◽

Cited By ~ 20

Author(s):

X. Lv ◽

Z. Wu ◽

C. Jiang ◽

Y. Li ◽

X. Yang ◽

...

Keyword(s):

Arteriovenous Malformation ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Venous Drainage ◽

Endovascular Embolization ◽

Adjusted Relative Risk ◽

Brain Arteriovenous Malformation ◽

Kaplan Meier ◽

Complete Obliteration ◽

Risk Of Hemorrhage

This study estimated the risk and rates of intracranial hemorrhage (ICH) in patients harboring brain arteriovenous malformation (BAVM) after endovascular embolization. One hundred and forty-four consecutive patients with BAVM treated with endovascular embolization between 1998 and 2003 were retrospectively reviewed. The risk of ICH subsequent to endovascular embolization was studied using Kaplan-Meier curves. We reviewed 144 patients with BAVM treated with endovascular embolization. Two hundred and sixty-nine procedures were performed, 69 were performed with silk sutures, 18 with coils, 137 with NBCA and 36 with Onyx18. Twenty-three (16.0%) patients were treated with additional gamma-knife radiosurgery and one (0.7%) with additional surgical AVM excision. Complete obliteration of BAVMs was achieved in 20 patients (13.9%). During a mean follow-up of 5.9 years for the ICH group and 6.9 years for the non-ICH group, hemorrhages occurred in 11 (17.7%) of the ICH patients and in nine (11%) of the non-ICH group (p>0.1). The annual risk of hemorrhage was 3.0% and 1.6%, respectively. In the multivariate regression model, the adjusted relative risk (RR) for hemorrhage at initial presentation was 1.6 (95% CI 1.2–3.2; p>0.1). Deep venous drainage, male sex, age or AVM size were not significantly associated with subsequent hemorrhage. ICH and non-ICH groups did not differ in progression to subsequent ICH after endovascular embolization (log-rank X2 = 1.339, p>0.1) in survival analyses. The overall annual hemorrhage risk for all patients after endovascular embolization was 2.1%. Endovascular embolization alone or combined with gamma-knife radiosurgery or surgical treatment are able to decrease ICH occurrence compared to abstention.

Download Full-text

Cerebral arteriovenous malformation radiosurgery after intracranial hemorrhage: A case report and literature review

Medicinski pregled ◽

10.2298/mpns1708241j ◽

2017 ◽

Vol 70 (7-8) ◽

pp. 241-244

Author(s):

Bojan Jelaca ◽

Tomislav Cigic ◽

Vladimir Papic ◽

Mladen Karan ◽

Jagos Golubovic ◽

...

Keyword(s):

Case Report ◽

Arteriovenous Malformation ◽

Gamma Knife ◽

Intracranial Hemorrhage ◽

Good Condition ◽

Gamma Knife Radiosurgery ◽

Treatment Modalities ◽

Temporal Region ◽

Surgical Morbidity

Introduction. Treatment of cerebral arteriovenous malformations is very challenging and controversial in spite of current recommendations. Surgery is recommended in patients with hemorrhagic stroke, but in patients with good neurological status, when symptoms improve rapidly, the risk of surgical morbidity may be much higher than the risk of rebleeding. Case report. We report a case of a patient with an intracranial hemorrhage due to a ruptured arteriovenous malformation located in the right temporal region of the brain. Because of angiographic and anatomical features of the arteriovenous malformation (deep location and deep venous drainage, but also small arteriovenous malformation nidus size), radiosurgery was the preferred treatment modality. The patient was treated conservatively in the acute stage, and the arteriovenous malformation was subsequently completely eradicated with gamma knife radiosurgery. During the 3-year imaging follow-up, no sings of rebleeding were found. Also, angiography demonstrated that the arteriovenous malformation was completely excluded from the cerebral circulation. The patient was in a good condition and presented without neurological deficits or seizures during the follow-up period. Conclusion. All treatment modalities carry a risk of neurological compromise, but gamma knife radiosurgery may be a good option, even in cases with hemorrhagic presentation. It needs to be mentioned that complete obliteration takes approximately 1 to 3 years after the treatment, and in some cases it cannot be obtained.

Download Full-text