Long-term Outcomes After Staged-Volume Stereotactic Radiosurgery for Large Arteriovenous Malformations

Huang, Paul P.; Rush, Stephen; Donahue, Bernadine R.; Narayana, Ashwatha; Becske, Tibor; Nelson, Peter Kim; Han, Kerry; Jafar, Jafar J.

doi:10.1227/neu.0b013e31825fd247

Cited by 36 publications

(45 citation statements)

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“…There are scarce reports on staged SRS that showed 28% to 29% rate of angiographic obliteration with 11% to 13% of adverse events and 4% to 5% risk of hemorrhage in the latency period. 9,10 Although these results may not seem promising, it must be noted that the majority of patients included in these series had excessively large volumes (>20 cm 3 ) relatively low marginal doses <18 Gy were applied to avoid adverse radiation effects in the earlier cases and additional SRS increased the obliteration rates to 56% at 10 years. 9 Evidently, the reduction of hemorrhage risk in the present series from 11.1% before treatment to 1.9% after treatment seemed preferable.…”

Section: Discussionmentioning

confidence: 95%

“…This approach seems to have treatment effects to certain extent, but the results are not favorable, showing <30% obliteration rates at 5 years with adverse events observed in 11% to 13% of the cases. 9,10 Here, we review the results of a single-session SRS for a nidus volume ranging from 10 to ≈20 cm 3 and speculate the efficacy and volume limit for a single-session SRS treatment strategy for patients with AVMs.…”

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confidence: 99%

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Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³

Hanakita

Koga

Shin

et al. 2014

Stroke

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Background and Purpose-Stereotactic radiosurgery (SRS) is a safe and effective treatment for small arteriovenous malformations (AVMs), the use of this modality for the treatment of large AVMs is still controversial, although it has been used in difficult cases. The aim of this study was to evaluate the treatment outcomes of patients who underwent single-stage SRS for large AVMs and to discuss the role of SRS in the treatment of these challenging lesions. Methods-Between 1998 and 2010, 65 patients with AVMs >10 cm 3 underwent single-stage SRS using the Leksell Gamma Knife. Patients who had prospective volume-staged SRS were excluded from this series. Outcomes including the rates of obliteration, hemorrhage after treatment, and adverse events were retrospectively evaluated. Results-The mean nidus volume was 14.9 cm 3 (±3.8 cm 3 ), and a mean margin dose of 20 Gy (±1.5 Gy) was applied. The mean observation period was 60 months (range, 7-178 months). The nidus obliteration rates after SRS were 44%, 76%, and 81% at 3, 5, and 6 years, respectively. The annual hemorrhage rate after SRS was 1.94% and permanent adverse events were observed in 2 patients (3%). Conclusions-For

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Section: Discussionmentioning

confidence: 95%

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confidence: 99%

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³

Hanakita

Koga

Shin

et al. 2014

Stroke

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“…9,25,27,44 The second most common presenting symptom was hemorrhage in 10%, 38 18%, 44 37.5%, 27 50%, 9 and 55% 25 of the cases. The reported rates of neurological deficits were 3.5%, 44 19.1%, 27 20%, 38 and 27.7%.…”

Section: Patient Characteristics In Svr Studiesmentioning

confidence: 99%

“…Larger AVMs might extend to more than 1 area of the brain. Approximately 90% of SVR-treated AVMs are graded as Spetzler-Martin Grade IV or V. 12,16,25,27,38,44 The average SRS margin dose ranged from 14.6 to 21 Gy. Initial volumes, number of SRS sessions, interval between sessions, and radiation doses are listed in Table 1.…”

Section: Patient Characteristics In Svr Studiesmentioning

confidence: 99%

Staged-volume radiosurgery for large arteriovenous malformations: a review

Alkhalili¹,

Chalouhi²,

Tjoumakaris³

et al. 2014

FOC

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Stereotactic radiosurgery is an effective management strategy for properly selected patients with arteriovenous malformations (AVMs). However, the risk of postradiosurgical radiation-related injury is higher in patients with large AVMs. Multistaged volumetric management of large AVMs was undertaken to limit the radiation exposure to the surrounding normal brain. This strategy offers a promising method for obtaining high AVM obliteration rates with minimal normal tissue damage. The use of embolization as an adjunctive method in the treatment of large AVMs remains controversial. Unfortunately, staged-volume radiosurgery (SVR) has a number of potential pitfalls that affect the outcome. The aim of this article is to highlight the role of SVR in the treatment of large AVMs, to discuss the outcome comparing it to other treatment modalities, and to discuss the potential improvement that could be introduced to this method of treatment.

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“…Twenty-six articles were then selected, among which 11 were excluded from the analysis due to insufficient follow-up time (less than 24 months), overlapping data from previous studies, reporting of actuarial obliteration rates without clear indication of exact number of AVMs obliterated at the end of the follow-up period, and inadequate specification of staging methods. The remaining 15 studies were subsequently classified by staging method, yielding 8 series 7,29,32,33,42,48,51,54 comprising 234 patients treated with HSRT and 7 series 2,5,10,23,26,31,43 comprising 167 patients treated with volume-staged SRS. Figure 1 is a flowchart depicting the systematic review process.…”

Section: Literature Searchmentioning

confidence: 99%

Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations

Moosa

Chen

Ding

et al. 2014

FOC

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Object The aim in this paper was to compare the outcomes of dose-staged and volume-staged stereotactic radio-surgery (SRS) in the treatment of large (> 10 cm3) arteriovenous malformations (AVMs). Methods A systematic literature review was performed using PubMed. Studies written in the English language with at least 5 patients harboring large (> 10 cm3) AVMs treated with dose- or volume-staged SRS that reported post-treatment outcomes data were selected for review. Demographic information, radiosurgical treatment parameters, and post-SRS outcomes and complications were analyzed for each of these studies. Results The mean complete obliteration rates for the dose- and volume-staged groups were 22.8% and 47.5%, respectively. Complete obliteration was demonstrated in 30 of 161 (18.6%) and 59 of 120 (49.2%) patients in the dose- and volume-staged groups, respectively. The mean rates of symptomatic radiation-induced changes were 13.5% and 13.6% in dose- and volume-staged groups, respectively. The mean rates of cumulative post-SRS latency period hemorrhage were 12.3% and 17.8% in the dose- and volume-staged groups, respectively. The mean rates of post-SRS mortality were 3.2% and 4.6% in dose- and volume-staged groups, respectively. Conclusions Volume-staged SRS affords higher obliteration rates and similar complication rates compared with dose-staged SRS. Thus, volume-staged SRS may be a superior approach for large AVMs that are not amenable to single-session SRS. Staged radiosurgery should be considered as an efficacious component of multimodality AVM management.

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Long-term Outcomes After Staged-Volume Stereotactic Radiosurgery for Large Arteriovenous Malformations

Abstract: Staged-volume radiosurgery for AVMs larger than 15 mL is a viable treatment strategy. The long-term occlusion rate is high, whereas the radiation-related complication rate is low. Hemorrhage during the lag period remains the greatest source of morbidity and mortality.

Cited by 36 publications

References 50 publications

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³

Staged-volume radiosurgery for large arteriovenous malformations: a review

Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations

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Long-term Outcomes After Staged-Volume Stereotactic Radiosurgery for Large Arteriovenous Malformations

Abstract: Staged-volume radiosurgery for AVMs larger than 15 mL is a viable treatment strategy. The long-term occlusion rate is high, whereas the radiation-related complication rate is low. Hemorrhage during the lag period remains the greatest source of morbidity and mortality.

Cited by 36 publications

References 50 publications

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm 3

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm 3

Staged-volume radiosurgery for large arteriovenous malformations: a review

Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations

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Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³

Application of Single-Stage Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations >10 cm ³