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.
Case rate payments combined with utilization monitoring may have the potential to improve the quality of care by reducing over and under-treatment. Thus, a national managed care organization introduced case rate payments at one multi-site radiation oncology provider while maintaining only fee-for-service payments at others. This study examined whether the introduction of the payment method had an effect on radiation fractions administered when compared to clinical guidelines. The number of fractions of radiation therapy delivered to patients with bone metastases, breast, lung, prostate, and skin cancer was assessed for concordance with clinical guidelines. The proportion of guideline-based care ascertained from the payer's claims database was compared before (2011) and after (2013) the payment method introduction using relative risks (RR). After the introduction of case rates, there were no significant changes in guideline-based care in breast, lung, and skin cancer; however, patients with bone metastases and prostate cancer were significantly more likely to have received guideline-based care (RR = 2.0 and 1.1, respectively, p<0.05). For the aggregate of all cancers, the under-treatment rate significantly declined (p = 0.008) from 4% to 0% after the introduction of case rate payments, while the over-treatment rate remained steady at 9%, with no significant change (p = 0.20). These findings suggest that the introduction of case rate payments did not adversely affect the rate of guideline-based care at the provider examined. Additional research is needed to isolate the effect of the payment model and assess implications in other populations.
Treatment of arteriovenous malformations (AVMs) is complicated because of many factors including increasing size, eloquent location, and risk of unacceptable neurological deficits. Each of the treatment modalities, microsurgery, embolization, and stereotactic radiosurgery (SRS), has its pros and cons. Surgery and embolization are limited by location, size, and afferent and efferent vessel anatomy. Stereotactic radiosurgery is limited by size and location, with increasing volume of the AVM resulting in decreasing the therapeutic dose. Many articles address the concern of high dose radiation not being able to be used in SRS over a large volume. [1][2][3][4][5] Embolization is an endovascular treatment that often precedes surgical excision or stereotactic radiosurgery for the treatment of AVMs. [6][7][8] This type of combination is typically utilized for larger AVMs (>3 cm 3 ) in order to reduce the overall size needed to be treated through microsurgical removal or SRS. 6,7,9,10 Staged gamma knife radiosurgery (GKRS) provides another method of treating larger AVMs and is based on the idea of safe re-treatment; however, unlike re-treatment which occurs approximately three years after the first treatment, staged SRS is multiple treatments over shorter period of time (~3 to 8 months). [11][12][13][14] We present a case showing successful obliteration of a large AVM in a 12-year-old male through the use of embolization to initially reduce nidus size followed by staged gamma knife radiosurgery. To the author's knowledge successful obliteration of a large AVM by combining staged embolization with stagedvolume GKRS has not previously been described. CASE MATERIAL Patient HistoryA 12-year-old male presented with complaints of dizziness and severe headaches. The patient did not describe any other complaints. The physical exam and family history were unremarkable. A CT scan was ordered and revealed a large (22.6 cc) and complex left posterior parietal cortical AVM. Further investigations included MRI and conventional 4-vessel angiography. Treatment PlanMicrosurgery was deemed inappropriate because of the AVM size. In addition, the volume of the AVM prevented the use of a single gamma knife treatment. A plan was organized that consisted of using staged-embolization to reduce the AVM nidus volume followed by staged-GKRS treatments to complete obliteration. As is important for any staged-GKRS treatment, MRI was used to plan the staged radiosurgical treatments. A flow Adam G. Back, Otto Zeck, Clive Shkedy, Peter M. Shedden Can. J. Neurol. Sci. 2009; 36: 500-503 BRIEF COMMUNICATIONS chart of the overall treatment plan is shown in Figure 1. EMBOLIZATION In order to reduce the volume of the AVM prior to GKRS the patient had three successful embolization procedures using Onyx as the embolization material. Catherization was performed with a transfemoral approach using standard coaxial techniques. The three embolization treatments were performed over a six-month Staged Embolization with Staged Gamma Knife Radiosurgery to Treat a...
BACKGROUND Metastatic cancer may involve the central and peripheral nervous system, usually in the late stages of disease. At this point, most patients have been diagnosed and treated for widespread systemic disease. Rarely is the involvement of the peripheral nervous system the presenting manifestation of malignancy. One reason for this is a proposed “blood-nerve barrier” that renders the nerve sheath a relatively privileged site for metastases. OBSERVATIONS The authors presented a novel case of metastatic melanoma presenting as intractable leg pain and numbness. Further workup revealed concurrent disease in the brain and breast, prompting urgent treatment with radiation and targeted immunotherapy. LESSONS This case highlights the rare presentation of metastatic melanoma as a mononeuropathy. Although neurological complications of metastases tend to occur in later stages of disease after initial diagnosis and treatment, one must remember to consider malignancy in the initial differential diagnosis of mononeuropathy.
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