Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Ding, Dale; Xu, Zhiyuan; Shih, Han-Hsun; Starke, Robert M.; Yen, Chun-Po; Cohen-Inbar, Or; Sheehan, Jason P.

doi:10.1227/neu.0000000000001409

Cited by 15 publications

(5 citation statements)

References 72 publications

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“…However, Feutren et al 54 reported a much higher rate of radiologic brain edema (66%) in his series of 48 patients treated with CyberKnife (Accuray, Sunnyvale, California, United States) for AVMs. Ding et al 51 reported that the rates of radiologic, symptomatic, and permanent RICs (35%, 10%, and 4%, respectively) were not significantly different in the two cohorts of patients with repeat SRS versus those with initial SRS. Matsuo et al 52 reported post-LINAC-SRS actuarial symptomatic radiation injury rates of 12.3%, 16.8%, and 19.1%, at 5, 10, and 15 years, respectively, and they recommended long-term observation after SRS for AVMs.…”

Section: Discussionmentioning

confidence: 99%

“…These changes, usually observed from 6 to 18 months after SRS, are frequently transient and reversible (i.e., resolving over weeks or a few months). 4,11,22,26,27,[51][52][53][54] Ilyas et al, 53 based on pooled data from 51 studies, reported that $ 1 in 3 patients with AVMs treated with SRS develops radiologically evident RIC, and of those, 1 in 4 patients develops neurologic symptoms. The present study showed 20.9%, 33.9%, and 12.9% rates of transient, persistent, and symptomatic RICs, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Less likely, it could be related to persistent but nonenhancing brain edema. 22,51,55 A literature review revealed that the most commonly reported factors associated with favorable outcome of SRS for AVMs were ruptured AVMs, lower AVM grade, smaller AVM volume, and a higher marginal dose. 11,19,52,[56][57][58][59] The present study showed that Spetzler-Martin grades I to III, AVM volumes 10 cc, and, more significantly, the appearance of perinidal T2 hyperintensity signal in post-SRS follow-up MRIs were independent predictors of AVM obliteration, which is consistent with other AVM SRS series.…”

Section: Discussionmentioning

confidence: 99%

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Correlation of Appearance of MRI Perinidal T2 Hyperintensity Signal and Eventual Nidus Obliteration Following Photon Radiosurgery of Brain AVMs: Combined Results of LINAC and Gamma Knife Centers

Abdelaziz

Shereen

Inoue

et al. 2019

J Neurol Surg A Cent Eur Neurosurg

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Background A wide variety of radiologic changes occur within and adjacent to the nidus of arteriovenous malformations (AVMs) after stereotactic radiosurgery (SRS). Our objective was to study the magnetic resonance imaging(MRI)-defined changes following photon radiosurgery of AVMs and specifically to correlate the appearance of a perinidal T2 hyperintensity signal with the eventual angiographic obliteration of an AVM nidus in response to SRS treatment. Material and Methods This retrospective study was conducted on 62 patients with brain AVMs who received photon SRS treatments between 2004 and 2017, using either a technique based on a linear accelerator at the Alexandria LINAC Radiosurgery Center in Egypt (21 patients/AVMs) or a technique based on a gamma unit at the Koto Memorial Gamma Knife Center in Japan (41 patients/AVMs). All patients included in the study had serial clinical and radiologic follow-ups for ≥ 2 years after SRS treatments. Results In the combined study series of 62 patients/AVMs treated with photon SRS, the follow-up MRIs revealed that 50 AVMs (80.6%) showed nonvisualized nidus and 12 AVMs (19.4%) showed decreased nidus size. Radiation-induced changes, defined as appearance of perinidal T2 hyperintensities in post-SRS MRIs, occurred in 34 patients (54.8%). Of the 35 patients with available follow-up angiographic studies, 30 AVMs (85.7%) demonstrated complete nidus obliteration at a mean of 36 months (range: 8–66 months) after SRS. Of the 30 AVMs with both MRI evidence of a nonvisualized nidus and angiographic verification of complete nidus obliteration, 20 AVMs (66.7%) were associated with prior MRI evidence of the appearance of a perinidal T2 hyperintensity signal at an average of 12 months (range: 6–45 months) after SRS. Of the five AVMs with both MRI evidence of decreased nidus size and angiographic verification of partial nidus obliteration, four AVMs (80%) showed perinidal T2 hyperintensity signal on post-SRS follow-up MRIs. Lower Spetzler-Martin grade (p = 0.013), smaller AVM volume (p = 0.017), and appearance of post-SRS perinidal T2 hyperintensity signal (p = 0.007) were the statistically significant independent predictors of AVM obliteration. The appearance of perinidal T2 hyperintensity signal in the post-SRS MRIs had a sensitivity of 66.7%, a specificity of 20%, and an overall accuracy of 60% in predicting the eventual obliteration of the AVM nidus. Conclusions The present study may help improve our current understanding of the mechanisms behind the radiation-induced tissue changes following AVM SRS. Because the SRS-induced hemodynamic changes within the AVM nidus initiate the cascade of the subsequent formation of perinidal vasogenic brain edema, the appearance of perinidal high T2 signal in the follow-up MRIs after SRS would be a valuable indicator of the AVM response to SRS. The development of perinidal hyperintensity was the strongest predictive factor of AVM obliteration (p = 0.007), with relatively high sensitivity (66.7%) and accuracy (60%) and fairly low specificity (20%), as a prognostic sign of eventual complete angiographic obliteration of the AVM nidus following SRS.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Correlation of Appearance of MRI Perinidal T2 Hyperintensity Signal and Eventual Nidus Obliteration Following Photon Radiosurgery of Brain AVMs: Combined Results of LINAC and Gamma Knife Centers

Abdelaziz

Shereen

Inoue

et al. 2019

J Neurol Surg A Cent Eur Neurosurg

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“…21 However, prior nidal embolization has been shown to be a negative prognostic factor for post-SRS AVM obliteration, and repeat SRS may yield worse outcomes than initial SRS. 10,21 Due to the risk of hemorrhage and its associated morbidity and mortality, complete nidal obliteration remains the primary goal of any AVM treatment. SRS is an effective treatment for pediatric AVMs, especially for those not amenable to surgery, with reported obliteration rates ranging from 60% to 80% at 4-5 years after SRS.…”

Section: Discussionmentioning

confidence: 99%

Stereotactic radiosurgery for pediatric brain arteriovenous malformations: long-term outcomes

Chen

Lee

Kano

et al. 2020

Journal of Neurosurgery: Pediatrics

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OBJECTIVEContrary to the better described obliteration- and hemorrhage-related data after stereotactic radiosurgery (SRS) of brain arteriovenous malformations (AVMs) in pediatric patients, estimates of the rarer complications, including cyst and tumor formation, are limited in the literature. The aim of the present study was to assess the long-term outcomes and risks of SRS for AVMs in pediatric patients (age < 18 years).METHODSThe authors retrospectively analyzed the International Radiosurgery Research Foundation pediatric AVM database for the years 1987 to 2018. AVM obliteration, post-SRS hemorrhage, cyst formation, and tumor formation were assessed. Cumulative probabilities, adjusted for the competing risk of death, were calculated.RESULTSThe study cohort comprised 539 pediatric AVM patients (mean follow-up 85.8 months). AVM obliteration was observed in 64.3% of patients, with cumulative probabilities of 63.6% (95% CI 58.8%–68.0%), 77.1% (95% CI 72.1%–81.3%), and 88.1% (95% CI 82.5%–92.0%) over 5, 10, and 15 years, respectively. Post-SRS hemorrhage was observed in 8.4% of patients, with cumulative probabilities of 4.9% (95% CI 3.1%–7.2%), 9.7% (95% CI 6.4%–13.7%), and 14.5% (95% CI 9.5%–20.5%) over 5, 10, and 15 years, respectively. Cyst formation was observed in 2.1% of patients, with cumulative probabilities of 5.5% (95% CI 2.3%–10.7%) and 6.9% (95% CI 3.1%–12.9%) over 10 and 15 years, respectively. Meningiomas were observed in 2 patients (0.4%) at 10 and 12 years after SRS, with a cumulative probability of 3.1% (95% CI 0.6%–9.7%) over 15 years.CONCLUSIONSAVM obliteration can be expected after SRS in the majority of the pediatric population, with a relatively low risk of hemorrhage during the latency period. Cyst and benign tumor formation after SRS can be observed in 7% and 3% of patients over 15 years, respectively. Longitudinal surveillance for delayed neoplasia is prudent despite its low incidence.

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“…The elevated risk of both initial and repeat hemorrhage for these deep-seated CCMs compared to cortical CCMs favors intervention, whereas the relatively high rate of neurological morbidity associated with surgical resection of these lesions supports a more conservative approach 41)42). Although radiosurgery is a conceptually attractive alternative to surgical resection of eloquent CCMs, the radiosurgery-induced complication rate is significantly higher for CCMs than for AVMs, and CCMs cannot be radiologically monitored for obliteration after radiosurgery 3)5)6)8)9)10)12)13)14)15)16)17)18)19)20)21)22)23)25)26)27)28)29)30)31)32)33)34)35)36)37)43)44)49)50)52)53)56)59)63)64)65)66)67)68). Instead, the proposed effect of radiosurgery on CCMs is a decreased risk of symptomatic hemorrhages, which is controversial due to temporal clustering of CCM hemorrhages 4).…”

Section: Discussionmentioning

confidence: 99%

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

Ding

Starke

Crowley

et al. 2017

J Cerebrovasc Endovasc Neurosurg

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ObjectiveSurgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem.Materials and MethodsWe reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated.ResultsA total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%.ConclusionMicroneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.

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Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Abstract: AVM, arteriovenous malformationRIC, radiation-induced changeRBAS, radiosurgery-based arteriovenous malformation scoreSRS, stereotactic radiosurgeryVRAS, virginia radiosurgery AVM scale.

Cited by 15 publications

References 72 publications

Correlation of Appearance of MRI Perinidal T2 Hyperintensity Signal and Eventual Nidus Obliteration Following Photon Radiosurgery of Brain AVMs: Combined Results of LINAC and Gamma Knife Centers

Correlation of Appearance of MRI Perinidal T2 Hyperintensity Signal and Eventual Nidus Obliteration Following Photon Radiosurgery of Brain AVMs: Combined Results of LINAC and Gamma Knife Centers

Stereotactic radiosurgery for pediatric brain arteriovenous malformations: long-term outcomes

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

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