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Prog Neurol Surg [journal]
- Series Editor's Note. Gamma knife radiosurgery. [Introductory Journal Article]
- Prog Neurol Surg 2013.:VII.
- Stereotactic radiosurgery guidelines for the management of patients with intracranial dural arteriovenous fistulas. [Journal Article, Review]
- Prog Neurol Surg 2013.:218-26.
Treatment options for dural arteriovenous fistulas (DAVFs) have expanded with the application of stereotactic radiosurgery (SRS). Our objective was to provide guidelines about the use of SRS in symptomatic patients with imaging-identified DAVFs of the brain. The authors reviewed evidence-based medicine and clinical experience with radiosurgery for DAVFs of the brain and developed guidelines and provided a scientific foundation for patients and physicians. Major recommendations include the definition of DAVF patients suitable for various management strategies ranging from observation to surgical excision to endovascular embolization and SRS. Combined SRS and embolization is an effective management strategy for DAVFs, including those that have recurred after initial embolization. The effect of prior embolization has been evaluated. SRS before embolization facilitates the better recognition of the entire target. For selected DAVF patients who are not eligible for embolization or surgery, SRS alone is an effective treatment option. The dose range for DAVFs is similar to that of arteriovenous malformations. A clinical algorithm for the potential role of SRS for a symptomatic brain DAVF was defined. These guidelines provide a framework for professional judgment and treatment selection alternatives for the management of DAVFs.
- Dural arteriovenous fistulas and the role of gamma knife stereotactic radiosurgery: the Stockholm experience. [Journal Article]
- Prog Neurol Surg 2013.:205-17.
We review the clinical and radiological outcomes of patients with dural arteriovenous fistulae (DAVFs), treated with the Gamma Knife® (GK) in Stockholm. During the period 1972-2008, 73 consecutive patients were treated. Eight were excluded due to lack of follow-up. Thus, the material comprises 65 patients harboring 67 DAVFs subjected to 75 treatments with GK stereotactic radiosurgery (SRS). Fifty-four cases were subjected to upfront GK SRS while 13 followed failed surgery or embolization. Nine patients had been retreated with GK SRS. One was recent and was excluded. Prescription doses varied considerably, but most commonly it was 20-25 Gy to the 40-60% isodose. Target definition was from angiography in all cases. 63 cases had an angiographic follow-up. There were 37 (59%) obliterations and 17 (27%) regressions. Nine lesions were unchanged (14%). If patients with clinical data suggestive of obliteration or magnetic resonance imaging follow-up are included, the numbers differ. Two patients are excluded. As for the 73 remaining cases, there were 46 (63%) obliterations, 17 (23%) regressions and 10 (14%) unchanged. There were 2 posttreatment hemorrhages and 5 minor adverse radiation effects. GK SRS is an effective treatment for DAVFs, with a low incidence of complications. GK SRS is a treatment alternative for patients harboring a DAVF without cortical venous reflux that causes intolerable bruit and to those not amenable to embolization or surgery.
- Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas. [Comparative Study, Journal Article]
- Prog Neurol Surg 2013.:195-204.
Treatment options for symptomatic dural arteriovenous fistulas (DAVFs) include surgery, embolization and stereotactic radiosurgery (SRS). We reviewed our DAVF experience at the University of Pittsburgh and assessed the role of SRS. We evaluated 40 consecutive patients who underwent Gamma Knife SRS for 44 DAVFs. Twenty-eight patients had upfront SRS before or after embolization performed at our institution, and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median SRS target volume was 2.0 cm3, and the median marginal dose was 21.0 Gy. At a median follow-up of 45 months (range, 23-116 months), a total of 28 patients with 32 DAVFs had obliteration. The obliteration rate was 83% for patients who had upfront SRS and embolization. The obliteration rate was lower (67%) for patients managed with SRS alone. The obliteration rate was 71% for patients who had delayed SRS for recurrent or residual DAVFs following prior embolization. In our experience cavernous/carotid fistulas were associated with higher rates of obliteration and symptomatic improvement compared to transverse/sigmoid sinus region fistulas. Our experience suggests that successful DAVF obliteration is possible in most patients with upfront SRS in conjunction with embolization. SRS alone is an effective treatment for selected patients with a small-volume, low-risk DAVF.
- Intracranial dural arteriovenous fistulas: natural history and rationale for treatment with stereotactic radiosurgery. [Journal Article, Review]
- Prog Neurol Surg 2013.:176-94.
Dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous communications within the dura. The symptoms depend on their location and the pattern of the venous drainage. Patients with cavernous sinus DAVFs often present with ocular manifestations such as exophthalmos, chemosis and diplopia. Patients with transverse or sigmoid sinus DAVFs frequently experience headache and tinnitus on the affected side. DAVFs with anterograde sinus or cortical venous drainage (CVD) have been clinically regarded as benign, whereas DAVFs with retrograde CVD are considered aggressive in behavior. Similar to other cerebral arteriovenous malformations, DAVFs can hemorrhage, with an estimated annual risk of approximately 1.8%. The recommended therapeutic intervention for a DAVF is dependent on the anticipated natural history of the lesion. Management options include surgical resection, embolization and radiosurgery. Radiosurgical treatment has been used for DAVFs in various locations including the anterior cranial fossa, cavernous sinus, transverse/sigmoid sinus, superior sagittal sinus and tentorium. We present an update on 321 DAVF patients treated at the Taipei Veterans General Hospital using Gamma Knife radiosurgery. The prescribed mean margin dose was 17.2 Gy. In our series, 98% of patients had a stable or improved clinical condition after radiosurgery. Stereotactic radiosurgery using the Gamma Knife is a safe and effective alternative for the treatment of DAVFs.
- Stereotactic radiosurgery guidelines for the management of patients with intracranial cavernous malformations. [Journal Article, Review]
- Prog Neurol Surg 2013.:166-75.
Treatment options for cavernous malformations (CMs) have expanded with the application of stereotactic radiosurgery. In this report, we provide guidelines about the use of stereotactic radiosurgery in CM patients who had 2 documented symptomatic hemorrhages. We reviewed the evidence-based medicine and clinical experience with radiosurgery for CM of the brain and developed guidelines and provided a scientific foundation for patients and physicians. We also reviewed the controversy surrounding CM radiosurgery and discussed its origin and validity. Our recommendations include the selection of CM patients suitable for various management strategies ranging from observation to surgical excision and stereotactic radiosurgery. Radiosurgery is an effective management strategy that reduces the risk of additional hemorrhages from CMs that repeatedly bleed. The marginal dose ranges from 12 to 18 Gy (median 16 Gy). A clinical algorithm for the potential role of stereotactic radiosurgery for CM patients with 2 or more symptomatic hemorrhages is defined. These guidelines provide a framework for professional judgment and assessment of management alternatives for selected intracranial CMs.
- Radiosurgical treatment for epilepsy associated with cavernomas. [Journal Article, Multicenter Study, Review]
- Prog Neurol Surg 2013.:157-65.
Cavernous malformations (CMs) are congenital vascular malformations of the brain, which often present with drug-resistant epilepsy. Microsurgical excision remains the preferred approach for cortical-subcortical epileptogenic CMs that are not located in functional cortex. For patients presenting with seizures arising from eloquent cortex surrounding the lesion, radiosurgery appears to be a suitable alternative. We evaluated the effectiveness of Gamma Knife (GK) surgery in the management of drug-resistant seizures associated with CMs in a retrospective multicenter study. Forty-nine patients with cortical or subcortical CMs with severe long-term drug-resistant epilepsy underwent radiosurgery. The mean duration of epilepsy before these GK procedures was 7.5 (±9.3) years. The mean frequency of seizures was 6.9/month (±14). The mean marginal radiation dose was 19.17 Gy. At the last follow-up examination, 53% were seizure free. A highly significant decrease in the number of seizures was achieved for another 20%. The remaining 26% of patients showed little or no improvement. The morbidity was low. Radiosurgery is a promising management modality for epilepsy associated with CMs. The determination of the extent of the epileptogenic zone in CMs and dose selection are the critical steps towards successful radiosurgical outcome. Further prospective work is necessary to validate our data.
- Radiosurgery of brain cavernomas--long-term results. [Journal Article]
- Prog Neurol Surg 2013.:147-56.
The radiosurgery of cavernomas remains a controversial issue. The only way to verify the positive effect of the treatment is by clinical observation during a longer follow-up period, where a decreased annual risk of rebleeding should be observed after the latent interval inherent to radiosurgery. Besides this, an improvement in clinical symptoms (e.g. secondary epilepsy) and regression of the treated lesion might also be observed. In a group of 112 patients with brain cavernomas treated in our centre between 1992 and 2000 with the marginal dose of a median 16 Gy, the risk of bleeding decreased from 2% before the treatment to 0.5% after 2 years' latent interval (median follow-up 84 months). A decrease in the extent of the cavernoma was observed in 53% of cases and an increase in 6.4%. Epilepsy, if present before the treatment, improved in 45% of cases. The risk of temporary and permanent morbidity caused by radiosurgery was 14.6 and 0.9%, respectively. This morbidity can be reduced by a lower marginal dose, and future studies should show if repeated radiosurgery decreases the risks from a natural course of the disease in those cases where the initial radiosurgery failed.
- Cavernous malformations and hemorrhage risk. [Journal Article]
- Prog Neurol Surg 2013.:141-6.
Widespread availability of magnetic resonance imaging has helped our understanding of the natural history of cavernous malformations (CMs) of the brain. CMs present with diverse clinical manifestations. Supratentorial CMs are often identified incidentally. The clinical presentation corresponds with lesion location. Symptomatic, hemorrhagic CMs of the brainstem pose a challenging clinical problem as they are often associated with high surgical morbidity. In order to study the natural history of CM, we performed a prospective analysis on a series of patients who were sent to us for management. During the mean prospective follow-up interval of 34 months, 9 hemorrhages occurred. History of prior hemorrhage was the most important risk factor for subsequent hemorrhage. The annual hemorrhage was 0.6% in patients who never had a symptomatic hemorrhage. Patients who had prior hemorrhage have a higher (4.5%) annual hemorrhage rate.
- Stereotactic radiosurgery guideline for the management of patients with intracranial arteriovenous malformations. [Journal Article, Review]
- Prog Neurol Surg 2013.:130-40.
Our objective was to provide guidelines about the use of stereotactic radiosurgery in symptomatic patients with imaging-identified arteriovenous malformations (AVMs) of the brain. We reviewed evidence-based medicine and clinical experience with radiosurgery for AVM of the brain to develop guidelines and provide scientific foundation for patients and physicians. Major recommendations include the definition of AVM patients suitable for various management strategies ranging from observation to surgical excision to endovascular embolization and stereotactic radiosurgery. The optimal dose range for volumetric conformal AVM stereotactic radiosurgery has been largely established based on location and volume of the AVM. The relationship to prior embolization or prior surgery has been evaluated. The role of repeat radiosurgery has been assessed for those patients with incomplete obliteration of their AVM after 3 years have elapsed. The causes of failure of stereotactic radiosurgery have also been identified. A clinical algorithm for the potential role of stereotactic radiosurgery for a symptomatic brain AVM was defined. The guidelines provide a framework for professional judgment and treatment selection alternatives.