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Raki C, Davies L, Lai LT. Microsurgery alone versus preoperative embolisation: A meta-analysis of outcomes in brain AVMs by Spetzler-Martin grade. J Clin Neurosci 2025; 136:111209. [PMID: 40184823 DOI: 10.1016/j.jocn.2025.111209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2025] [Revised: 03/07/2025] [Accepted: 03/24/2025] [Indexed: 04/07/2025]
Abstract
Preoperative embolisation is frequently used an adjunct to microsurgery for brain arteriovenous malformations (AVMs), yet high-level evidence supporting its routine use remains limited. This meta-analysis compares outcomes of microsurgery alone versus combined microsurgery and preoperative embolisation, stratified by Spetzler-Martin (SM) grade. A systematic review of Embase, Medline, Scopus, Emcare, and the Cochrane Library identified 43 studies encompassing 3916 patients, equally divided between microsurgery alone (n = 1958) and combination therapy (n = 1958). Primary endpoints included functional dependence (modified Rankin Scale score > 2), angiographic obliteration, haemorrhagic complications, and intraoperative blood loss. Pooled analyses demonstrated no significant differences in functional dependence (OR 0.65, 95 % CI 0.32-1.32, p = 0.21), obliteration rates (OR 1.15, 95 % CI 0.60-2.19, p = 0.63), haemorrhagic complications (OR 1.67, 95 % CI 0.71-3.95, p = 0.20), or intraoperative blood loss (MD -98.90 mL, 95 % CI -417.38-219.57, p = 0.44). Subgroup analysis for SM grade I-II and III-V AVMs found no significant differences in outcomes between treatment modalities. For SM grade III AVMs, angiographic cure rates were comparable, though data scarcity precluded a robust assessment of functional dependence, postoperative haemorrhage, and intraoperative blood loss. While theoretical advantages exist for preoperative embolisation in higher-grade or high-flow AVMs, current evidence does not demonstrate consistent benefits in outcomes or complication rates. Further studies, particularly for SM grade III AVMs, are needed to determine whether combination therapy provides a meaningful advantage over microsurgery alone.
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Affiliation(s)
- Cyrus Raki
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Lily Davies
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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Sun MH, Tsuei YS, Wang TW, Liu SY, Chen YJ, Shen CC, Yang MY, Sheehan J, You WC, Sheu ML, Pan HC. Outcomes of gamma knife treated large symptomatic arteriovenous malformations according to guidelines of Taiwan neurosurgical consensus. Radiat Oncol 2025; 20:89. [PMID: 40426252 PMCID: PMC12117737 DOI: 10.1186/s13014-025-02667-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2024] [Accepted: 05/13/2025] [Indexed: 05/29/2025] Open
Abstract
Background The treatment of large arteriovenous malformations (AVMs), in particular those unruptured, remains a topic of debate. Stereotactic radiosurgery has favorable outcomes for small to medium-sized AVMs. However, for large AVMs, the goal is to maximize obliteration rates and at the same time, to minimize radiation-induced complications. This study assessed outcomes of large symptomatic AVMs treated with Gamma Knife radiosurgery (GKRS) focusing on cases presenting with rupture or seizures. The study followed the guidelines of Taiwan Neurosurgical Consensus, a government-funded committee under the Central Bureau of Health Insurance that determines whether radiosurgery is an appropriate treatment. Materials and methods This retrospective study included 75 cases of large AVMs (> 10 cc) treated with GKRS during the period from June 2003 to January 2020. Inclusion criteria were as follows: a history of intracerebral hemorrhage (ICH) or seizures, no prior embolization, and periodic MRI examinations with clinical assessments post-GKRS. Treatment procedures were adapted based on the Taiwan Neurosurgical Consensus guidelines. Results The average patient age was 36.4 ± 16.1 years, with a median follow-up duration of 104 (range 82–150) months. Forty-six patients (61.3%) underwent single-stage treatment, while 29 patients (38.7%) received two-stage treatment. The mean AVM volume was 20.5 ± 11.7 cc, with an average peripheral radiation dose of 17.7 ± 1.2 Gy. Among the 32 cases with AVM volumes between 10 and 15 cc, 25 (78.1%) achieved total obliteration. For the 17 cases with volumes between 15 and 20 cc, 7 (41.2%) achieved total obliteration, while 8 out of 26 (30.8%) cases with volumes > 20 cc achieved total obliteration. Severe brain edema developed in 16 patients (21.3%) after an average follow-up of 105.4 ± 56.2 months, but 11 patients (14.6%) experienced symptoms. Only one patient (1.3%) suffered neurological disability. Seizure control in Engel classification I was achieved in 21 of 42 patients (50%). Eight patients (10.6%) experienced new hemorrhages, with 4 (12.1%) occurring in those with a prior history of hemorrhage (annual bleeding rate: 1.2%) and 4 (9.5%) in those patients with a history of seizures (annual bleeding rate: 1.1%). Univariate analyses showed that total obliteration was significantly associated with smaller nidus volumes (< 15 cc), single-stage radiosurgery, Radiosurgery-Based Grading Scale, first-stage volume, maximum dose, 12 Gy volume, and nidus coverage percentages at 16 Gy and 18 Gy. Multivariate analyses revealed that post-GKRS symptoms and severe brain edema were significantly correlated with the following: Virginia Radiosurgery AVM Score, Charlson Comorbidity Index, and mean radiation dose. Conclusion The obliteration rate of large AVMs is strongly correlated with their size. This approach appears to achieve the goals of obliteration and minimizing the risks of radiation-induced complications and hemorrhage. Further investigation is needed for adjuvant treatments in residual or refractory cases after GKRS.
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Affiliation(s)
- Ming-Hsi Sun
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yuang-Seng Tsuei
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ting-Wei Wang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Szu-Yuan Liu
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ying Ju Chen
- PhD program in Health and Social Welfare for Indigenous Peoples, Providence University, Taichung, Taiwan
| | - Chiung-Chyi Shen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meng-Yin Yang
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meei-Ling Sheu
- Institute of Biomedical Science, National Chung-Hsing University, Taichung, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, Taichung, 40705, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung-Hsing University, Taichung, Taiwan
| | - Hung-Chuan Pan
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan.
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, Taichung, 40705, Taiwan.
- Rong Hsing Research Center for Translational Medicine, National Chung-Hsing University, Taichung, Taiwan.
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Thrash GW, Evans RE, Sun Y, Roberts AC, Derryberry C, Hale AT, Das S, Boudreau H, George JA, Atchley TJ, Blount JP, Rocque BG, Johnston JM, Jones JG. Stereotactic radiosurgery treatment of pediatric arteriovenous malformations: a PRISMA systematic review and meta-analysis. Childs Nerv Syst 2025; 41:188. [PMID: 40407914 PMCID: PMC12102109 DOI: 10.1007/s00381-025-06835-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2025] [Accepted: 05/01/2025] [Indexed: 05/26/2025]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is considered a safe definitive treatment for pediatric arteriovenous malformations (AVMs) upon indicated presentations. There are no published guidelines by the International Stereotactic Radiosurgery Society (ISRS) detailed with indications or characteristics that warrant SRS, other than the guideline that SRS is a safe and efficacious treatment for pediatric AVMs. SRS is performed using either Gamma Knife (GK) or Linear Accelerator (LINAC). This systematic review aims to uncover treatment, differences in GK and LINAC outcomes, and AVM characteristics that lead to high obliteration rates and suggest future studies to determine treatment decisions, raise obliteration rates, and lower complication rates in SRS treatment of pediatric AVMs. METHODS We performed a systematic review according to PRISMA guidelines across PubMed, Embase, and SCOPUS utilizing search terms related to pediatric patients, AVMS, and SRS. We collected data from the 32 full-text studies and 4 abstracts that met inclusion criteria. Subsequent pooled analysis was performed on GK vs LINAC obliteration rates, followed by sub-cohort analysis of all SRS patients with hemorrhagic presentation, Spetzler-Martin (SM) Grade, and prior procedure and their effect on obliteration rates. RESULTS The 36 studies reported 3425 patients, with a slight male preponderance (1662 patients, 48.5%). The obliteration analysis included 2834 patients that met follow-up criteria and contained obliteration data. The weighted mean age was 12.63 years. Pooled cohort analysis found no significant difference in obliteration proportions when comparing GK to LINAC (P = 0.7449), with an overall obliteration rate of 63% in patients with at least 1 year follow-up. The sub-cohort analysis of all patients treated with SRS revealed that presentation with AVM hemorrhage was associated with increased obliteration (CE: RR = 1.22 [95%CI = 1.09-1.35; RE: RR = 1.22, 95%CI = 10.6-1.40; prediction interval = 1.07-1.38) with low heterogeneity (I2 = 17.1%, τ2 < 0.0001, p = 0.2902). Smaller SM grade was not statistically associated with increased obliteration (CE: RR = 1.25 [95%CI = 0.87-1.81]; RE: RR = 1.84 [95%CI = 0.97-3.50]; prediction interval = 0.38-8.86) and moderate levels of heterogeneity were detected (I2 = 45.2%, τ2 = 0.2668, p = 0.1042). Procedure prior to SRS also had higher obliteration rates than no prior procedure (CE: RR = 0.77 [95%CI = 0.61-0.86]; RE: RR = 0.71 [95%CI = 0.54-0.92]; prediction interval = 0.36-1.39) with low to moderate heterogeneity (I2 = 27.6%, τ2 = 0.0.0264, p = 0.2466). CONCLUSION SRS is a safe and effective treatment for pediatric AVMs. This study suggests that there are no differences in obliteration between GK and LINAC, with increased obliteration in patients with hemorrhage at presentation and procedures prior to SRS treatment. Further multicenter, prospective studies are necessary to dictate future treatment decisions.
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Affiliation(s)
- Garrett W Thrash
- Heersink School of Medicine, University of Alabama at Birmingham, FOT Suite, 1720 2nd Ave S, Birmingham, AL, 35294, USA.
| | - Riley Ethan Evans
- Heersink School of Medicine, University of Alabama at Birmingham, FOT Suite, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Yifei Sun
- Heersink School of Medicine, University of Alabama at Birmingham, FOT Suite, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Anne C Roberts
- Heersink School of Medicine, University of Alabama at Birmingham, FOT Suite, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Cameron Derryberry
- Heersink School of Medicine, University of Alabama at Birmingham, FOT Suite, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Somnath Das
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hunter Boudreau
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jordan A George
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Travis J Atchley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey P Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon G Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Diagnostic Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Rammeloo E, Young JS, Schouten JW, Bos EM, Hervey-Jumper SL, Jungk C, Krieg SM, Smith T, Rincon-Torroella J, Bettegowda C, Maruyama T, Wagner A, Schucht P, Broekman MLD, De Vleeschouwer S, Nahed BV, Berger MS, Vincent AJPE, Gerritsen JKW. Preoperative assessment of tumor eloquence and resectability: an international survey. J Neurooncol 2025:10.1007/s11060-025-05067-0. [PMID: 40397319 DOI: 10.1007/s11060-025-05067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2025] [Accepted: 04/29/2025] [Indexed: 05/22/2025]
Abstract
BACKGROUND AND OBJECTIVES Tumor location and its proximity to eloquent brain areas are key factors in glioma surgery decision-making. However, the absence of a consensus definition for eloquent brain areas leads to variability in surgical decision-making. This survey aimed to assess this heterogeneity in defining eloquent brain regions. METHODS A survey was distributed among neurosurgeons in the United States, Europe, Latin America, and Australasia between February and November 2023. Respondents rated the eloquence of various brain structures on a Likert scale and reported their use of preoperative techniques. Twelve glioma and glioblastoma cases were presented to assess opinions on tumor location eloquence and preferred surgical approaches. RESULTS 157 neurosurgeons from 25 countries responded to the survey. Two-thirds (68%) agreed on the need for a standardized definition of eloquence, while only 23% applied existing eloquence grading scales. Eloquence ratings varied, with the highest variation reported for the corona radiata, uncinate fasciculus and superior longitudinal fasciculus. In patient cases, variability was observed at four levels of decision-making: (1) degree of eloquence; (2) preferred surgical modality; (3) use of intraoperative mapping; (4) the preferred mapping modality (asleep or awake). CONCLUSIONS This survey highlights the variability in defining eloquence and its impact on glioma surgery decision-making. This lack of consensus limits the reliability of eloquence as a descriptor of tumor location, affecting patient care and comparability across studies. Future research should focus on the development of an easy-to-use, objective method (based on intraoperative data) for identifying eloquent brain regions preoperatively.
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Affiliation(s)
- Emma Rammeloo
- Department of Neurosurgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Jacob S Young
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Joost W Schouten
- Department of Neurosurgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Eelke M Bos
- Department of Neurosurgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | | | - Christine Jungk
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandro M Krieg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Timothy Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | | | - Arthur Wagner
- Department of Neurosurgery, Technical University Munich, Munich, Germany
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital University Hospital Bern, Bern, Switzerland
| | - Marike L D Broekman
- Department of Neurosurgery, Haaglanden Medical Center, and Leiden University Medical School, The Hague, The Netherlands
| | | | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mitchel S Berger
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Arnaud J P E Vincent
- Department of Neurosurgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jasper K W Gerritsen
- Department of Neurosurgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Neurosurgery, University of California, San Francisco, CA, USA
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Miller S, Abualnadi Y, Wondwossen T, Hassan A. Endovascular treatment of unruptured Spetzler-Martin grade IV and V brain AVMs in a predominantly Hispanic patient cohort. Interv Neuroradiol 2025:15910199251339540. [PMID: 40398467 PMCID: PMC12095200 DOI: 10.1177/15910199251339540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2025] [Accepted: 04/16/2025] [Indexed: 05/23/2025] Open
Abstract
BackgroundEndovascular embolization (EE) of brain arteriovenous malformations (bAVM) has historically carried high risk and low efficacy. In the setting of improved endovascular devices and embolization techniques this is changing. This is especially important for high grade, unruptured bAVMs as their management remains controversial.MethodsThis is a single center case series using a prospectively maintained database. Included patients underwent EE with intent to cure of unruptured Spetzler-Martin grade IV or V bAVMs from August 2015 to May 2023. Baseline, clinical and bAVM characteristics were recorded. Outcomes of interest included angiographic cure, intracranial hemorrhage (ICH), persistent neurological deficits (PND), change in baseline functional status and mortality.ResultsTwelve patients (median 27yo, 50% female, 92% Hispanic) underwent a total of 53 EE. Eight had grade IV and four had grade V bAVM. Median AVM size was 48.6 mm (IQR 44.8-68.1). All patients underwent both transarterial and transvenous embolization. Of the eleven patients who completed treatment, eight achieved angiographic cure with endovascular embolization alone and two with adjunct stereotactic radiosurgery (SRS). One patient experienced intraprocedural microwire vessel perforation with no associated long-term sequelae. No patient experienced PND or post-procedural ICH. All patients were at their neurological baseline on last follow-up. There were zero mortalities.ConclusionWe observed a high rate of angiographic cure, low rate of adverse events and no disability or mortality in patients who underwent EE of high-grade unruptured bAVM. This suggests with improved endovascular capabilities and careful patient selection, endovascular treatment of high-grade AVMs should be considered when clinically indicated.
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Affiliation(s)
- Samantha Miller
- Neuroscience Department, Valley Baptist Medical Center Harlingen, Harlingen, TX, USA
| | - Yazan Abualnadi
- Neuroscience Department, Valley Baptist Medical Center Harlingen, Harlingen, TX, USA
| | - Tekle Wondwossen
- Neuroscience Department, Valley Baptist Medical Center Harlingen, Harlingen, TX, USA
| | - Ameer Hassan
- Neuroscience Department, Valley Baptist Medical Center Harlingen, Harlingen, TX, USA
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Tugend M, Joncas CT, Chang YF, Jaoui Y, Sekula RF. Update and Evaluation of a Preoperative Scoring System to Predict Long-Term Outcomes After Microvascular Decompression in Trigeminal Neuralgia. Oper Neurosurg (Hagerstown) 2025:01787389-990000000-01592. [PMID: 40391987 DOI: 10.1227/ons.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Accepted: 01/15/2025] [Indexed: 05/22/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Scoring systems attempting to predict long-term pain relief after microvascular decompression (MVD) for trigeminal neuralgia (TN) have been published previously. We compare the Panczykowski scoring system and a new scoring system, developed in response to published criticisms of previous scoring systems, in a larger cohort with longer term follow-up. METHODS In this retrospective cohort study, records from 410 patients undergoing MVD for TN were reviewed. Pain freedom after MVD was recorded, and Panczykowski scores (scoring system A) were calculated. Univariate logistic regression models were used to determine the relationship between clinical characteristics and pain freedom at follow-up. The predictive value of a tentative new scoring system was examined (scoring system B) and compared with scoring system A. RESULTS At a mean follow-up of 63 months, 282 patients (68.8%) were pain free without medications. Univariable analysis showed that age >45 years(χ2 = 6.26, df = 1, P = .012), TN type (χ2 = 53.16, df = 1, P < .0001), response to carbamazepine (χ2 = 6.65, df = 1, P = .010), and neurovascular compression (χ2 = 25.93, df = 1, P < .0001) all significantly predicted postoperative pain freedom without medication. Using scoring system A, a patient with a preoperative score of 3, 4, or 5 was, respectively, 2.05 (P = .114), 5.76 (95% CI 2.46-13.50, P < .0001), and 10.52 (95% CI 4.66-23.79, P < .0001) times more likely to attain long-term pain freedom without medication than a patient with a score of 0 or 1. Using scoring system B, a patient with a score of 3 or 4 was, respectively, 3.59 (95% CI 1.42-9.08, P = .007) and 8.68 (95% CI 3.42-22.05, P < .0001) times more likely to attain long-term pain freedom without medication than a patient with a score of 0 or 1. CONCLUSION In a larger cohort of patients with longer term follow-up, both scoring systems A and B reliably predict long-term pain freedom after MVD for TN in this patient population and may be beneficial in selecting patients most likely to benefit from surgery.
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Affiliation(s)
- Margaret Tugend
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Colby T Joncas
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yanis Jaoui
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Raymond F Sekula
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
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Yu J, Lu H, Krings T, Bian L, Feng Y, Li J, Yang F, Li G, He C, Ye M, Hu P, Sun L, Ma Y, Ren J, Ling F, Hong T, Zhang H. Microsurgery Versus Embolization for Spinal Cord Arteriovenous Malformations: A Proposed Grading System. Neurosurgery 2025:00006123-990000000-01643. [PMID: 40387316 DOI: 10.1227/neu.0000000000003458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 12/23/2024] [Indexed: 05/20/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Comparing microsurgery and embolization for spinal cord arteriovenous malformations (SCAVMs) is challenging because of the disease's rarity and the highly heterogeneous angioarchitecture. The aim of this study was to compare outcomes between microsurgery and embolization using a grading system for SCAVMs that effectively stratifies angioarchitectural complexities. METHODS A total of 714 patients were included, with 308 undergoing microsurgery. The grading system was developed based on independent risk factors of incomplete resection, including anterior sulcal artery supply, metameric manifestations, the maximum diameter of lesion, and lesion depth. Each parameter was assigned one point, stratifying angioarchitectural complexities of SCAVMs into five grades. RESULTS Microsurgery carried significantly higher treatment risks than embolization across all grades. For patients scoring 0 to 2 points, microsurgery achieved significantly higher complete obliteration rates than embolization. For patients scoring 3 or 4 points, the complete obliteration rates between the two methods were similar. Long-term clinical deterioration after microsurgery was significantly more frequent after embolization for patients scoring 1; for patients scoring 0, the higher long-term deterioration rate after embolization was also observed, but not statistically significant; for patients scoring 2 to 4 points, risks of long-term clinical deterioration between the two methods were comparable. At the last follow-up, the rate of poor prognosis was similar between the two methods for patients scoring 0 points. For the remaining groups, microsurgery showed a worse prognosis. CONCLUSION Embolization should be the primary treatment option for patients with SCAVMs; however, microsurgery should be considered as an alternative for patients scoring 0 or 1 point if endovascular treatment fails to achieve complete obliteration.
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Affiliation(s)
- Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Haohan Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Canada
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Yueshan Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
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Ji ZL, Xiang SS, Li JW, Xu J, Yu JX, Qi JW, Li GL, Zhang HQ. The Efficacy and Disadvantages of Endovascular Therapy for Deep-Seated Cerebral Arteriovenous Malformations: A Long-Term Follow-Up Study. J Craniofac Surg 2025:00001665-990000000-02735. [PMID: 40378007 DOI: 10.1097/scs.0000000000011486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2025] [Accepted: 04/13/2025] [Indexed: 05/18/2025] Open
Abstract
Arteriovenous malformations (AVMs) in the basal ganglia, the thalamus, and the insular lobe of the brain are rare and difficult-to-treat diseases that require integrated multimodal management. This study aimed to determine the safety and disadvantages of embolization as an independent therapy for deep-seated AVMs. The authors reviewed 76 patients from a single center with cerebral deep-seated AVMs from 2010 to 2020. Clinical hemorrhage refers to the initial clinical presentation with bleeding, the first occurrence of bleeding, and delayed postoperative hemorrhage refers to subsequent bleeding following the initial hemorrhage. After interventional therapy, 8 patients experienced delayed postoperative hemorrhage during the total follow-up of 94,631 person-years, with an annual postoperative hemorrhage rate of 3.1%. Compared with the overall clinical hemorrhage rate before treatment (15.9%/person-year), 11 patients experienced clinical hemorrhage during 25,238 person-years, indicating a significantly decreased risk of clinical hemorrhage after treatment. A total of 28.9% (22/76) of patients achieved angiographic obliteration. Multivariate analysis showed that pretreatment limb weakness and a high Spetzler-Martin grade predicted poor clinical outcomes (P = 0.043 and 0.005). Fewer feeding arteries predicted AVMs' obliteration (P = 0.048). Endovascular procedure-related complications, mortality, and morbidity were, respectively, reported in 7.9% (6/76), 1.3% (1/76), and 14.8% (8/54) of patients. Endovascular embolization significantly lowered the risk of clinical deterioration and delayed hemorrhage, indicating it to be a safe and effective therapy for deep-seated AVMs. Lesions with a simple angioarchitecture were more likely to be completely obliterated.
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Affiliation(s)
- Zhen-Long Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
- Department of Neurosurgery, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an
| | - Si-Shi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
| | - Jing-Wei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
| | - Jin Xu
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jia-Xing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
| | - Jia-Wei Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
| | - Gui-Lin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
| | - Hong-Qi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing
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9
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Raki C, Xenos C, Lai LT. Is Supplemented Spetzler-Martin grading Superior? A comparative study in AVM microsurgery risk stratification. J Clin Neurosci 2025; 137:111311. [PMID: 40349589 DOI: 10.1016/j.jocn.2025.111311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2025] [Revised: 04/26/2025] [Accepted: 05/05/2025] [Indexed: 05/14/2025]
Abstract
The Spetzler-Martin (SM) grading system remains the most widely adopted classification for brain arteriovenous malformations (AVMs). The Supplemented Spetzler-Martin (Supp-SM) system was developed to improve surgical risk stratification by incorporating patient age, rupture status, and nidus diffuseness. However, data comparing its predictive validity remain limited. This study investigates the predictive relevance of SM and Supp-SM grading for postoperative neurological morbidity following AVM microsurgery at a single tertiary cerebrovascular centre. A retrospective review identified 96 patients who underwent AVM microsurgical resection, with or without preoperative embolisation, between 2015 and 2024. Postoperative morbidity was defined as worsened modified Rankin Scale (mRS) score at 90 days. Predictive accuracy was analysed using ROC curves, correlation with postoperative mRS scores, and Supp-SM risk threshold. Postoperative morbidity occurred in 9 patients (9.4 %). ROC analysis revealed no significant difference between SM (AUROC 0.717; 95 % CI 0.55-0.88) and Supp-SM (AUROC 0.667; 95 % CI 0.46-0.88) scores, p = 0.3899. However, Supp-SM scores demonstrated a stronger correlation with postoperative mRS changes (Spearman's ρ = 0.269, p = 0.008) than SM grades (Spearman's ρ = 0.144, p = 0.161). Patients with Supp-SM grades < 6 had a 3.2 % morbidity risk, compared with a 20.6 % risk for scores ≥ 6 (p = 0.009). A Supp-SM threshold of 6 demonstrated the highest discriminative accuracy in differentiating high- and low-risk surgical candidates. While no significant predictive difference was found between SM and Supp-SM grading, a Supp-SM score of ≥ 6 was associated with substantially higher morbidity. These findings support the adjunctive use of Supp-SM grading for surgical risk assessment in AVM patients.
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Affiliation(s)
- Cyrus Raki
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Chris Xenos
- Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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Makhambetov Y, Maidan A, Mammadinova I, Menlibayeva K, Kunakbayev B, Dyussembaev S, Nurakay N, Makhambetov N, Almabayeva A, Nurimanov C. The Dynamics of Seizures After Microsurgical Treatment of Brain AVMs in Patients with Symptomatic Epilepsy: A Single-Center Experience over 10 Years. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:856. [PMID: 40428814 PMCID: PMC12113111 DOI: 10.3390/medicina61050856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Revised: 04/06/2025] [Accepted: 05/04/2025] [Indexed: 05/29/2025]
Abstract
Background and Objectives: Arteriovenous malformations (AVMs) are abnormal connections between arteries and veins, lacking a normal capillary network. Seizures are a common clinical manifestation in patients with brain AVMs, ranking as the second most frequent presentation. The objective of this study was to evaluate the dynamics of seizure activity in patients with brain AVMs following surgical treatment. Materials and Methods: This study included 27 patients with brain AVMs who underwent microsurgical AVM resection for symptomatic epilepsy. All surgical interventions were performed at JSC "National Centre for Neurosurgery" between 2008 and 2020. Results: Over an average follow-up period of 98.07 ± 45.6 months, 82 patients with brain AVMs underwent open microsurgical resection at the National Centre for Neurosurgery. Among them, 27 patients presented with seizures and had complete follow-up information, qualifying them for inclusion in this study. The participants had a mean age of 32.59 ± 9.06 years, with 13 of them being women. The Spetzler-Martin grading system was used to classify the AVMs: 6 patients had grade 1, 13 had grade 2, 7 had grade 3, and 1 had grade 4. More than half of the patients experienced generalized seizures. Microsurgical removal of the AVMs resulted in seizure remission for all patients. Only one patient experienced postoperative hemorrhage during the follow-up period. Additionally, one patient developed acute postoperative anemia, which resolved with a favorable outcome. Conclusions: Microsurgical resection of brain AVMs, when performed with careful patient selection, leads to a significant reduction in seizure activity. It is a safe and effective treatment option for symptomatic epilepsy associated with brain AVMs.
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Affiliation(s)
- Yerbol Makhambetov
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Aiman Maidan
- Taraz City Multidisciplinary Hospital and Consulting and Diagnostic Center, Taraz 080000, Kazakhstan
| | - Iroda Mammadinova
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Karashash Menlibayeva
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Baurzhan Kunakbayev
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Serik Dyussembaev
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Nurtay Nurakay
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Nursultan Makhambetov
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
| | - Aigul Almabayeva
- Anatomy Faculty, Astana Medical University, Astana 010000, Kazakhstan;
| | - Chingiz Nurimanov
- National Centre for Neurosurgery, Astana 010000, Kazakhstan; (Y.M.); (I.M.); (K.M.); (B.K.); (S.D.); (N.N.); (N.M.); (C.N.)
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11
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Ueki Y, Naylor RM, Ghozy SA, Thirupathi K, Rinaldo L, Kallmes DF, Kadirvel R. Advances in sporadic brain arteriovenous malformations: Novel genetic insights, innovative animal models and emerging therapeutic approaches. J Cereb Blood Flow Metab 2025; 45:793-799. [PMID: 39948029 PMCID: PMC11826813 DOI: 10.1177/0271678x251319913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 01/27/2025] [Accepted: 01/27/2025] [Indexed: 02/16/2025]
Abstract
Brain arteriovenous malformations (bAVMs) are a notable cause of intracranial hemorrhage, strongly associated with severe morbidity and mortality. Contemporary treatment options include surgery, stereotactic radiosurgery, and endovascular embolization, each of which has limitations. Hence, development of pharmacological interventions is urgently needed. The recent discovery of the presence of activating Kirsten rat sarcoma (KRAS) viral oncogene homologue mutations in most sporadic bAVMs has opened the door for a more comprehensive understanding of the pathogenesis of bAVMs and has pointed to entirely novel possible therapeutic targets. Herein, we review the status quo of genetics, animal models, and therapeutic approaches in bAVMs.
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Affiliation(s)
- Yasuhito Ueki
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
- Department of Neurosurgery, Faculty of Medicine, The University of Juntendo, Tokyo, Japan
| | - Ryan M Naylor
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | - Sherief A Ghozy
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | | | - Lorenzo Rinaldo
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
| | | | - Ramanathan Kadirvel
- Department of Neurologic Surgery, Mayo Clinic Rochester, MN, USA
- Department of Radiology, Mayo Clinic Rochester, MN, USA
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12
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Beucler N. Highly cited scores, scoring systems, grading systems, and classifications of daily use in cranial neurosurgery: A must-have during residency training! A mini-review. Neurochirurgie 2025; 71:101646. [PMID: 39947122 DOI: 10.1016/j.neuchi.2025.101646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2025] [Accepted: 02/04/2025] [Indexed: 05/24/2025]
Abstract
CONTEXT Neurosurgery has much evolved since the time of Kocher and Cushing. Thanks to operative microscope, radiation therapy, progress of neuroresuscitation care, and data from evidence-based neurosurgical research, neurosurgery patients' prognostic has improved. Now more than ever, we need simple, reliable, and reproducible scores, grades, and classifications to assist us in the surgical decision making, to assess patients' clinical evolution, and to conduct proper neurosurgical research. MATERIALS AND METHODS We conducted a three stage scoping review: (1) identification of sections of interest: brain trauma, tumor, vascular, infection, stroke, functional outcome (2) identification of the most common diseases within each section, (3) we retained every score, scale, classification that is internationally recognized and/or highly cited and/or used daily in clinical practice or research setting and/or that is currently used by the author. RESULTS 23 scores were retained. Brain trauma section: Glasgow coma scale (1974), Glasgow Liège scale (1982), SHE score (2019), RASH score (2022). Tumor section: Karnofsky Performance status (1948), Graded Prognostic Assessment (2008), Simpson grade (1957), Sindou grade (2006), House and Brackmann (1983), Koos grade (1993), Knosp scale (1993). Vascular section: PHASES score (2014), UIATS score (2015), Hunt and Hess scale (1968), Fisher scale (1980), WFNS scale (1988), Spetzler Martin scale (1986), Borden scale (1995), Cognard scale (1995), Zabramski scale (1995). Stroke section: ICH score (2001), NIHSS (1989). Functional outcome section: Rankin scale (1957). CONCLUSION We provide a non-exhaustive list of 23 reference scales, scores, and classifications that can be safely used for cranial neurosurgery clinical practice and research.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800 Toulon Cedex 9, France.
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13
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Noorbakhsh A, Wong MT, Bolar DS. Evaluating post-treatment residual intracranial arteriovenous shunting: a comparison of arterial spin labeling MRI and digital subtraction angiography. Neuroradiology 2025; 67:1233-1250. [PMID: 39912896 DOI: 10.1007/s00234-025-03548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 01/13/2025] [Indexed: 02/07/2025]
Abstract
PURPOSE To evaluate the efficacy of arterial spin labeling (ASL) MRI in detecting residual arteriovenous (AV) shunting in treated arteriovenous malformations (AVMs) and fistulas (AVFs). METHODS A retrospective institutional review identified 29 patients with DSA-confirmed AV shunt lesions treated via embolization (n = 17), stereotactic radiosurgery (n = 2), surgical resection (n = 8), or combined embolization and surgical resection (n = 4), with corresponding baseline and post-treatment ASL and DSA studies. Two neuroradiologists independently assessed ASL images for residual AV shunting, with inter-rater agreement calculated. Disagreements were jointly reviewed to reach consensus. Sensitivity and specificity for using ASL to detect residual AV shunting were then determined using DSA as the gold standard reference. RESULTS Seventeen patients with Spetzler-Martin grades II-V AVMs were included: 76.5% with supratentorial nidus, and 52.9% with prior hemorrhage. Twelve AVF patients were included, including eight dural, one vein of Galen, two perimedullary, and one cavernous-carotid fistula. Inter-rater agreement for presence of residual AV shunting was strong (93.5%, κ = 0.87). Two disagreements involved AVM patients after surgical resection. Sensitivity and specificity of ASL for detecting residual was 94% and 93%, respectively. Within the AVM group, both metrics reached 100%, while for AVFs, they both decreased to 83%, with one false positive and one false negative. CONCLUSION ASL MRI is highly sensitive and specific for detection of residual AV shunting across a wide spectrum of AV shunt pathologies and treatment modalities. ASL can play an important role as a non-invasive adjunct to DSA, potentially reducing the frequency of DSA during the continuum of post-treatment care.
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Affiliation(s)
- Abraham Noorbakhsh
- Department of Radiology, University of California San Diego, La Jolla, CA, USA.
- Department of Radiology, Kaiser Permanente Medical Center San Diego, San Diego, CA, USA.
| | - Mitchell T Wong
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - Divya S Bolar
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
- Center for Functional MRI, University of California San Diego, 9500 Gilman Drive MC 0677, La Jolla, CA, 92093, USA
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14
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Keenan JS, Har C, Yan F, Sepeta L, Staso K, Conley CR, Sansevere AJ, Harrar DB. Association of Physiologic Parameters with Neurologic Outcome After Arteriovenous Malformation Rupture in Children. J Child Neurol 2025:8830738251330110. [PMID: 40266567 DOI: 10.1177/08830738251330110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2025]
Abstract
Evidence to guide the critical care management of children with ruptured brain arteriovenous malformations is lacking. We aimed to determine whether there are associations between physiologic parameters and outcome in children with ruptured brain arteriovenous malformations. We performed a single-center retrospective review of patients ≤18 years of age with a ruptured brain arteriovenous malformation from 2011 to 2023. Categorization of outcome was based on the Pediatric Stroke Outcome Measure. Descriptive statistics were used. Most patients with an arteriovenous malformation rupture had a poor outcome at discharge (31/49, 63%) and in follow-up at 3-12 months (21/37, 57%). Patients who were normothermic and normoglycemic for the first 7 days after arteriovenous malformation rupture were less likely to have a poor outcome at discharge than those who had a temperature ≥38 °C (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.04-0.52; P = .01) or a blood glucose ≥200 mg/dL (OR 0.11, 95% CI 0.01-0.92; P = .04). A lower minimum hemoglobin concentration (10.00 g/dL [standard deviation (SD) 1.67] vs 12.46 g/dL [SD 6.29], t(47) 2.07, P = .04) and a higher average partial pressure of carbon dioxide (Paco2) (40.98 mm Hg [SD 4.30] vs 35.58 mm Hg [SD 7.72], t(47) -2.09, P = .046) were also associated with a poor discharge outcome. A higher average maximum temperature was associated with a poor outcome in follow-up (37.46° C [SD 0.49] vs 37.09 °C [SD 0.59], t(47) -2.09; P = .04). Temperature, blood glucose, hemoglobin concentration, and Paco2 are potentially modifiable parameters that could be targeted by quality improvement interventions to improve outcomes in this population.
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Affiliation(s)
- Julia S Keenan
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Claire Har
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Florence Yan
- Departments of Neurology and Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Leigh Sepeta
- Department of Neuropsychology, Children's National Hospital, Washington, DC, USA
| | - Katelyn Staso
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Caroline R Conley
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, Washington, DC, USA
- Departments of Neurology and Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
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15
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Goyal-Honavar A, Srinivas D, Konar S, Sadashiva N, Beniwal M, Prabhuraj AR, Arimappamagan A, Rao KVLN, Somanna S. Long-term outcomes and safety of Gamma Knife radiosurgery in pediatric arteriovenous malformations. Childs Nerv Syst 2025; 41:157. [PMID: 40232520 DOI: 10.1007/s00381-025-06776-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Accepted: 02/15/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE Despite the unique challenges presented by pediatric intracranial AVMs, little data is available on the use of GKRS in the pediatric population. Therefore, we aimed to present our experience with GKRS in treating pediatric AVMs, determining the factors that influence nidus obliteration and poor outcomes, with a focus on delayed complications. METHODS This retrospective review examined patients ≤18 years who underwent GKRS between January 2013 and December 2021 for intracranial AVMs. Factors that predicted residual nidus and poor outcomes were analyzed. The utility of AVM size reduction at follow-up in predicting eventual nidus obliteration was tested. RESULTS We treated 101 pediatric patients for AVMs with a mean age of 14.2 ± 2.8 years. The mean dose delivered was 22.7 ± 2.4 Gy. After a mean follow-up of 41.4 months, 78 AVMs (77.8%) were obliterated. Residual nidus was associated with prior embolization (HR 4.953; 95% CI 1.343, 18.268; p = 0.016) and age ≥14 years (HR 5.920; 95% CI 1.559, 22.480; p = 0.009) while presentation with bleed (HR 0.178; 95% CI 0.05, 0.631; p = 0.008) was protective. Reduction in size of a nidus during early follow-up closely correlated with eventual obliteration, with increasing accuracy at 6-month, 12-month, and 24-month follow-up (67.6%, 80.2%, and 86.5% respectively). Twelve patients developed perilesional edema, while one patient each developed a chronic encapsulated hematoma (CEH), cyst formation, and rebleed. Dose > 22 Gy (HR 25.641; 95% CI 2.257, 250; p = 0.009) and volume ≥ 3 cc (HR 7.189; 95% CI 1.176, 43.945; p = 0.033) predicted poor outcomes on multivariate analysis. CONCLUSIONS GKRS delivers a high rate of AVM nidus obliteration in the pediatric population, with prior embolization, older age, and unruptured presentation associated with residual nidus. The incidence of delayed complications, although low, warrants regular surveillance in the pediatric population due to their greater life expectancy.
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Affiliation(s)
- Abhijit Goyal-Honavar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India.
| | - Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Nishanth Sadashiva
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Manish Beniwal
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Andiperumal Raj Prabhuraj
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Arivazhagan Arimappamagan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Kannepalli V L Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, 560029, India
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16
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Roy JM, Musmar B, Majmundar S, Kaul A, Atallah E, Zanaty M, Sizdahkhani S, Mouchtouris N, Mastorakos P, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Predictors of angiographic occlusion after embolization of intracranial arteriovenous malformations with curative intent. Interv Neuroradiol 2025:15910199251332400. [PMID: 40232292 PMCID: PMC11999980 DOI: 10.1177/15910199251332400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Accepted: 03/17/2025] [Indexed: 04/16/2025] Open
Abstract
BackgroundEndovascular embolization is a potential alternative to open surgery for treating intracranial arteriovenous malformations (AVMs). To our knowledge, predictors of occlusion after curative embolization of AVMs remain limited in literature. Our study aims to identify predictors of radiographic occlusion after embolization of AVMs with curative intent.MethodsThis was a retrospective study of patients who underwent embolization of AVMs with curative intent at a single institution between 2007 and 2022. The primary outcome of cure was defined as radiographic occlusion of the AVM on follow-up. Univariate and multivariate analyses were performed with a P value <0.05 denoting statistical significance.ResultsSixty-six patients underwent embolization of an AVM with curative intent. The median (interquartile range (IQR)) age of the cohort was 53 (36-62), and 48.5% were male. 65.2% (n = 43) patients presented with hemorrhage. 59.1% (n = 39) of the cohort achieved cure on follow-up. Median (IQR) volume of AVM (mm3) and maximum pedicle size (mm) were significantly higher in patients who were not cured on follow-up compared to those who were cured: 14055.12 (2431.71-31235.60) and 1.9 (1.3-2.5) versus 3888 (2063-12518) and 1.3 (1.1-1.6), respectively. On multivariate regression, maximum pedicle size was associated with lower odds of cure (OR: 0.24, 95% CI: 0.07-0.82, P = 0.023).ConclusionsOur study identified maximum pedicle size to be the only significant factor associated with lower odds of radiographic occlusion after curative embolization of AVMs. Further multicenter studies are required to validate these findings.
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Affiliation(s)
- Joanna M Roy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Shyam Majmundar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Anand Kaul
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mario Zanaty
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Saman Sizdahkhani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Becerril-Gaitan A, Nguyen J, Lee CC, Ding D, Cifarelli CP, Liscak R, Williams BJ, Yusuf MB, Woo SY, Warnick RE, Trifiletti DM, Mathieu D, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Lee J, Sheehan JP, Chen CJ. Stereotactic Radiosurgery With Versus Without Neoadjuvant Endovascular Embolization for Brain Arteriovenous Malformations With Associated Intracranial Aneurysms. Neurosurgery 2025; 96:787-793. [PMID: 39171929 DOI: 10.1227/neu.0000000000003152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/13/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) with neoadjuvant embolization is a treatment strategy for brain arteriovenous malformations (AVMs), especially for those with large nidal volume or concomitant aneurysms. The aim of this study was to assess the effects of pre-SRS embolization in AVMs with an associated intracranial aneurysm (IA). METHODS The International Radiosurgery Research Foundation AVM database from 1987 to 2018 was retrospectively reviewed. SRS-treated AVMs with IAs were included. Patients were categorized into those treated with upfront embolization (E + SRS) vs stand-alone SRS (SRS). Primary end point was a favorable outcome (AVM obliteration + no permanent radiation-induced changes or post-SRS hemorrhage). Secondary outcomes included AVM obliteration, mortality, follow-up modified Rankin Scale, post-SRS hemorrhage, and radiation-induced changes. RESULTS Forty four AVM patients with associated IAs were included, of which 23 (52.3%) underwent pre-SRS embolization and 21 (47.7%) SRS only. Significant differences between the E + SRS vs SRS groups were found for AVM maximum diameter (1.5 ± 0.5 vs 1.1 ± 0.4 cm 3 , P = .019) and SRS treatment volume (9.3 ± 8.3 vs 4.3 ± 3.3 cm 3 , P = .025). A favorable outcome was achieved in 45.4% of patients in the E + SRS group and 38.1% in the SRS group ( P = .625). Obliteration rates were comparable (56.5% for E + SRS vs 47.6% for SRS, P = .555), whereas a higher mortality rate was found in the SRS group (19.1% vs 0%, P = .048). After adjusting for AVM maximum diameter, SRS treatment volume, and maximum radiation dose, the likelihood of achieving favorable outcome and AVM obliteration did not differ between groups ( P = .475 and P = .820, respectively). CONCLUSION The likelihood of a favorable outcome and AVM obliteration after SRS with neoadjuvant embolization in AVMs with concomitant IA seems to be comparable with stand-alone SRS, even after adjusting for AVM volume and SRS maximum dose. However, the increased mortality among the stand-alone SRS group and relatively low risk of embolization-related complications suggest that these patients may benefit from a combined treatment approach.
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Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Justin Nguyen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yan-Ming University, Taipei , Taiwan
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville , Kentucky , USA
| | | | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville , Kentucky , USA
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham , Alabama , USA
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville , Kentucky , USA
| | - Ronald E Warnick
- Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati , Ohio , USA
| | - Daniel M Trifiletti
- Department of Radiation Oncology, The Mayo Clinic, Jacksonville , Florida , USA
| | - David Mathieu
- Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke , Quebec , Canada
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York , New York , USA
| | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan , Puerto Rico , USA
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey , Pennsylvania , USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey , Pennsylvania , USA
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia , Pennsylvania , USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
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18
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Thomas M, Hoening D, Stauffer J, Atkins B. Encephaloduroarteriosynangiosis for the Treatment of Cerebral Arteriovenous Malformations in the Pediatric Population. Cureus 2025; 17:e81765. [PMID: 40330401 PMCID: PMC12052221 DOI: 10.7759/cureus.81765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Accepted: 04/05/2025] [Indexed: 05/08/2025] Open
Abstract
Arteriovenous malformations (AVMs) in the pediatric population are rare but represent a critical cause of spontaneous intracranial hemorrhage. Here we present the case of an 11-year-old boy who developed acute-onset left-sided weakness, slurred speech, and transient hemiparesis. While initial laboratory findings were unremarkable, brain magnetic resonance imaging revealed a large right cerebral AVM. Cerebral angiography confirmed this finding, showing a Spetzler-Martin grade V AVM, supplied by the middle, anterior, and posterior cerebral arteries. The patient was treated using a multimodal approach, including embolization and encephaloduroarteriosynangiosis (EDAS). Postoperatively, he experienced transient worsening of hemiparesis of unknown etiology, which gradually improved. Long-term follow-up demonstrated improved motor function with persistent mild left-sided weakness. This case highlights the significance of multimodal management in high-grade pediatric AVMs. This particular includes the utility of EDAS, originally developed for moyamoya disease, in mitigating ischemia by promoting collateral neovascularization and thus improving neurological symptoms.
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Affiliation(s)
- Matthew Thomas
- Pediatrics and Child Health, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Dirk Hoening
- General Surgery, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - John Stauffer
- Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Bethany Atkins
- Pediatrics, Baptist Health Jacksonville, Jacksonville, USA
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19
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Mosteiro A, Pedrosa L, Amaro S, Menéndez-Girón S, Reyes L, de Riva N, Misis M, Blasco J, Vert C, Dominguez CJ, Enseñat J, Martín A, Rodriguez-Hernández A, Torné R. Understanding the Importance of Blood-Brain Barrier Alterations in Brain Arteriovenous Malformations and Implications for Treatment: A Dynamic Contrast-Enhanced-MRI-Based Prospective Study. Neurosurgery 2025; 96:811-823. [PMID: 39264174 PMCID: PMC11882286 DOI: 10.1227/neu.0000000000003159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/23/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The major clinical implication of brain arteriovenous malformations (bAVMs) is spontaneous intracranial hemorrhage. There is a growing body of experimental evidence proving that inflammation and blood-brain barrier (BBB) dysfunction are involved in both the clinical course of the disease and the risk of bleeding. However, how bAVM treatment affects perilesional BBB disturbances is yet unclear. METHODS We assessed the permeability changes of the BBB using dynamic contrast-enhanced MRI (DCE-MRI) in a series of bAVMs (n = 35), before and at a mean of 5 (±2) days after treatment. A set of cerebral cavernous malformations (CCMs) (n = 16) was used as a control group for the assessment of the surgical-related collateral changes. The extended Tofts pharmacokinetic model was used to extract permeability (K trans ) values in the lesional, perilesional, and normal brain tissues. RESULTS In patients with bAVM, the permeability of BBB was higher in the perilesional of bAVM tissue compared with the rest of the brain parenchyma (mean K trans 0.145 ± 0.104 vs 0.084 ± 0.035, P = .004). Meanwhile, no significant changes were seen in the perilesional brain of CCM cases (mean K trans 0.055 ± 0.056 vs 0.061 ± 0.026, P = .96). A significant decrease in BBB permeability was evident in the perilesional area of bAVM after surgical resection (mean K trans 0.145 ± 0.104 vs 0.096 ± 0.059, P = .037). This benefit in BBB permeability reduction after surgery seemed to surpass the relative increase in permeability inherent to the surgical manipulation. CONCLUSION In contrast to CCMs, BBB permeability in patients with bAVM is increased in the perilesional parenchyma, as assessed using DCE-MRI. However, bAVM surgical resection seems to reduce BBB permeability in the perilesional tissue. No evidence of the so-called breakthrough phenomenon was detected in our series. DCE-MRI could become a valuable tool to follow the longitudinal course of BBB damage throughout the natural history and clinical course of bAVMs.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Leire Pedrosa
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Sergio Amaro
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Comprehensive Stroke Unit, Neurology, Hospital Clinic of Barcelona, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | | | - Luis Reyes
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Maite Misis
- Intensive Care Department, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Jordi Blasco
- University of Barcelona, Barcelona, Spain
- Interventional Neuroradiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carla Vert
- Neuroradiology Department, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Carlos J. Dominguez
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Abraham Martín
- Achucarro Basque Center for Neuroscience, Bizkaia, Spain
- Ikerbasque Basque Foundation for Science, Bilbao, Spain
| | - Ana Rodriguez-Hernández
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Ramon Torné
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Interventional Neuroradiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
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20
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Tos SM, Osama M, Mantziaris G, Hajikarimloo B, Adeeb N, Kandregula S, Salim HA, Musmar B, Ogilvy CS, Kondziolka D, Dmytriw AA, Naamani KE, Abdelsalam A, Kumbhare D, Gummadi S, Ataoglu C, Essibayi MA, Erginoglu U, Keles A, Muram S, Sconzo D, Riina H, Rezai A, Pöppe J, Sen RD, Kim LJ, Alwakaa O, Griessenauer CJ, Jabbour P, Tjoumakaris SI, Burkhardt JK, Starke RM, Baskaya MK, Sekhar LN, Levitt MR, Altschul DJ, Haranhalli N, McAvoy M, Abushehab A, Aslan A, Swaid C, Abla A, Stapleton C, Koch M, Srinivasan VM, Chen PR, Blackburn S, Choudhri O, Pukenas B, Orbach D, Smith E, Möhlenbruch M, Alaraj A, Aziz-Sultan A, Patel AB, Savardekar A, Cuellar HH, Dlouhy K, El Ahmadieh T, Lawton M, Siddiqui A, Morcos J, Guthikonda B, Sheehan J. Spetzler-martin grade IV cerebral arteriovenous malformations in adult patients: a propensity-score matched analysis of resection and stereotactic radiosurgery. Neurosurg Rev 2025; 48:337. [PMID: 40159532 PMCID: PMC11955433 DOI: 10.1007/s10143-025-03465-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 03/14/2025] [Accepted: 03/16/2025] [Indexed: 04/02/2025]
Abstract
Spetzler-Martin Grade IV arteriovenous malformations (AVMs) are challenging due to high risks associated with both treatment and natural progression. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) in high-grade AVMs, analyzing obliteration rates, complications, and functional outcomes. A retrospective cohort of 96 patients treated with either microsurgical resection (33 patients) or SRS (63 patients) was analyzed. Propensity-score matching was employed to account for baseline variables such as AVM size (cm), preoperative embolization and rupture status. Primary endpoints included AVM obliteration, complication rates, and modified Rankin Scale (mRS) scores. After matching, 31 patients per group were analyzed. Microsurgical resection achieved significantly higher obliteration rates (87.1%) compared to SRS (32.3%, p < 0.001). In the matched SRS cohort (n = 31), the actuarial obliteration rates were 11% (95% CI: 0-22%) at 1 year, 17% (95% CI: 0-31%) at 3 years, and 43% (95% CI: 13-63%) at 5 years post-treatment. Complication rates were similar (32.3% resection, 38.7% SRS, p = 0.6). Functional outcomes in terms of improvement in modified Rankin Scale (mRS) scores were observed in 50.0% of microsurgery patients and 41.4% of SRS patients. However, the absolute number of patients improving was similar (13 vs. 12), and the microsurgery group had more cases of worsening mRS scores compared to the SRS group (4 vs. 2). The difference was not statistically significant (p = 0.4). Microsurgical resection offers superior obliteration rates for high-grade AVMs with comparable complication risks to SRS. SRS remains a valuable alternative for select patients, particularly those ineligible for resection. Future research should focus on optimizing multimodal treatment approaches. Clinical trial number Not applicable.
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Affiliation(s)
- Salem M Tos
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Mahmoud Osama
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Georgios Mantziaris
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Bardia Hajikarimloo
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Hamza Adel Salim
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Basel Musmar
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Grossman School of Medicine, Manhattan, NY, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Sanjeev Gummadi
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Cagdas Ataoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Muhammed Amir Essibayi
- Montefiore Einstein Cerebrovascular Research Lab, Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - Ufuk Erginoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Abdullah Keles
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Sandeep Muram
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Sconzo
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Howard Riina
- Department of Neurosurgery, New York University Grossman School of Medicine, Manhattan, NY, USA
| | - Arwin Rezai
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Johannes Pöppe
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Rajeev D Sen
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Omar Alwakaa
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Laligam N Sekhar
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - David J Altschul
- Montefiore Einstein Cerebrovascular Research Lab, Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - Neil Haranhalli
- Montefiore Einstein Cerebrovascular Research Lab, Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - Malia McAvoy
- Department of Plastic Surgery, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Assala Aslan
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Christian Swaid
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Adib Abla
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Christopher Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Koch
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Peng R Chen
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Omar Choudhri
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Darren Orbach
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Markus Möhlenbruch
- Interventional Neuroradiology, Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois in Chicago, Chicago, IL, USA
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amey Savardekar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Hugo H Cuellar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Kathleen Dlouhy
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Tarek El Ahmadieh
- Department of Neurosurgery, Loma Linda University, Redlands, CA, USA
| | - Michael Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Jacques Morcos
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
- Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA, 22908, USA.
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21
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Alshuqayfi KM, AlDallal U, Albulaihed S, Atallah O, Sharma M, Al-Ghuraibawi MA, Algabri MH, Ismail M, Hoz SS. Cerebral arteriovenous malformation calcifications: A systematic review, case series, and a proposed classification system. Surg Neurol Int 2025; 16:104. [PMID: 40206768 PMCID: PMC11980719 DOI: 10.25259/sni_102_2025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2025] [Accepted: 02/06/2025] [Indexed: 04/11/2025] Open
Abstract
Background Brain arteriovenous malformations (AVMs) are intracranial vascular lesions characterized by a nidus of vessels fed by an artery and drained by a vein, lacking intervening capillaries. Angiography remains the gold standard for a definitive diagnosis. There is a paucity in the literature regarding clinical presentation and management of patients with calcified cerebral AVM (cCAVM). This study aims to highlight the clinical presentation and management of patients with cCAVM and also to propose a classification of calcification patterns in cCAVMs based on brain computed tomography (CT) findings. Methods A systematic review using PubMed, Scopus, and Web of Science was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify cases that illustrate cCAVM. A case series was also presented to supplement the current literature. Results Twenty patients with cCAVM were included, with the male gender representing more than 50% of the patient population. Their age ranged from 11 to 69 years, with seizures being the most common presenting symptom. The frontal lobe was the most common location of AVMs, followed by the parietal lobe. Most (80%) of the calcifications were nidal, with the remaining being extranidal (20%). Conclusion The CT scans of patients displayed significant variability due to the unique characteristics of each cCAVM. To address this diversity, a novel classification system was developed to provide a comprehensive framework for understanding cCAVMs based on their location, size, and extent.
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Affiliation(s)
- Khalid M. Alshuqayfi
- Department of Neurosurgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Usama AlDallal
- Department of Neurosurgery, University of Cambridge Addenbrooke’s Hospital Cambridge, Cambridge, United Kingdom
| | - Sadeem Albulaihed
- Department of Neurosurgery, Faculty of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Kentucky, United States
| | | | - Mostafa H. Algabri
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Mustafa Ismail
- Department of Surgery, Baghdad Teaching Hospital, Baghdad, Iraq
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio, United States
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22
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Lasica N, Gull HH, Sure U, Vulekovic P, Djilvesi D, Andjelic D, Jabbarli R, Deuschl C, Darkwah Oppong M. Risk factors for bleeding in patients with arteriovenous malformations associated with intracranial aneurysms. Neurosurg Rev 2025; 48:313. [PMID: 40117005 DOI: 10.1007/s10143-025-03468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 01/03/2025] [Accepted: 03/16/2025] [Indexed: 03/23/2025]
Abstract
BACKGROUND AND OBJECTIVES Natural history of brain arteriovenous malformations (bAVMs) with associated intracranial aneurysms (IAs) reveals a higher rate of hemorrhage. We aimed to identify the prevalence and risk factors for hemorrhage in a subgroup of patients with bAVMs and associated arterial IAs. METHODS The authors conducted an international, bicentric retrospective study of patients with ruptured and unruptured bAVMs with associated IAs treated at tertiary centers between January 2013 and December 2022. Sociodemographic data, clinical characteristics, and radiological parameters in patients with bAVM and associated IAs were analyzed. RESULTS Of 944 patients with bAVM, 137 individuals with 191 associated arterial IAs were included in the final analysis. Bleeding presentation was documented in 85 cases (62.0%). The mean size of bAVM-associated IAs was 6.8 (SD = 4.8) mm. Multiple intracranial aneurysms (MIA) were present in 35 patients (25.5%). bAVM-associated IAs were classified as nidal in 19.0%, flow-related in 73.7%, and unrelated in 7.3% of cases. Univariate analysis revealed that arterial hypertension (odds ratio 4.37 [CI 1.52-12.57]; P =.004), history of smoking (odds ratio 5.77 [CI 1.26-26.53]; P =.013), and high-grade bAVMs (grades IV/V, odds ratio 0.35 [CI 0.15-0.87]; P =.02), were associated with a bleeding risk. In the multivariable analysis, only arterial hypertension remained significantly associated with the bleeding event (adjusted odds ratio 3.37 [CI 1.07-10.58]; P =.038). CONCLUSIONS Observational data from our large bicentric cohort of patients with bAVM and associated IAs identified arterial hypertension as a risk factor associated with an increased risk of bleeding. TRIAL REGISTRATION The study was approved by the Institutional Review Board (IRB) of the University Clinical Center of Vojvodina and the University of Duisburg-Essen (20-9288-BO).
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Affiliation(s)
- Nebojsa Lasica
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia.
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia.
| | - Hanah Hadice Gull
- Department of Neurosurgery and Spine Surgery, University Hospital, University of Duisburg-Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University of Duisburg Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital, University of Duisburg-Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University of Duisburg Essen, Essen, Germany
| | - Petar Vulekovic
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Djula Djilvesi
- Clinic of Neurosurgery, University Clinical Center of Vojvodina, Novi Sad, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Dragan Andjelic
- Center for Radiology, University Clinical Center of Vojvodina, Novi Sad, Serbia
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital, University of Duisburg-Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University of Duisburg Essen, Essen, Germany
| | - Cornelius Deuschl
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital, University of Duisburg-Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University of Duisburg Essen, Essen, Germany
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23
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Isikbay M, Caton MT, Mattay R, Han W, Cooke DL, Raper D, Winkler EA, Savastano L, Narsinh KH, Hetts SW, Amans MR. Arteriovenous shunts of the cervical spine: patient demographics, presentation, patterns of high-risk venous drainage, and updated classification. J Neurointerv Surg 2025; 17:427-433. [PMID: 38604766 PMCID: PMC11913568 DOI: 10.1136/jnis-2023-021353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/27/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Intracranial dural arteriovenous (AV) fistula classifications focus on presence/absence of retrograde flow in the cortical veins of the brain as this angiographic finding portends a worse prognosis. However, prior categorization systems of AV shunts in the spine do not incorporate these features. We propose an updated classification for spinal shunting lesions that terms any shunting lesion with retrograde flow in any cortical vein of the brain or spinal cord medullary vein as "high risk". To present this classification, we analyzed our center's most recent experience with cervical spine shunting lesions. METHODS The electronic medical record at our institution was reviewed to identify shunting lesions of the cervical spine and patient demographics/presentation. Comprehensive craniospinal digital subtraction angiograms were evaluated to classify shunt location, type (arteriovenous malformation (AVM) vs arteriovenous fistula (AVF)), and presence of high-risk venous drainage. RESULTS Some 52 lesions were identified and categorized as pial/dural/epidural/paravertebral AVFs and intramedullary/extraspinal AVMs. Lesions were classified as high risk or not depending on the presence of retrograde flow into at least one vein that directly drains the spinal cord or brain. All patients who presented with either hemorrhage or infarct had underlying high-risk lesions. Additionally, 50% (17/34) of symptomatic patients with high-risk lesions presented with neurological extremity symptoms (OR=10.0, p=0.037) most of which fit a myelopathic pattern. CONCLUSION We present an updated classification system for shunting lesions of the spine that focuses on high-risk retrograde flow to the brain or spine in addition to anatomical location in order to better inform patient management.
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Affiliation(s)
- Masis Isikbay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Raghav Mattay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Woody Han
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel Raper
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Savastano
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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24
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Dockrell S, McCabe MG, Kamaly-Asl I, Kilday JP, Stivaros SM. Radiological Predictors of Cognitive Impairment in Paediatric Brain Tumours Using Multiparametric Magnetic Resonance Imaging: A Review of Current Practice, Challenges and Future Directions. Cancers (Basel) 2025; 17:947. [PMID: 40149283 PMCID: PMC11940392 DOI: 10.3390/cancers17060947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2025] [Revised: 03/06/2025] [Accepted: 03/08/2025] [Indexed: 03/29/2025] Open
Abstract
Paediatric brain tumours and their treatments are associated with long-term cognitive impairment. While the aetiology of cognitive impairment is complex and multifactorial, multiparametric Magnetic Resonance Imaging (MRI) can identify many risk factors including tumour location, damage to eloquent structures and tumour phenotype. Hydrocephalus and raised intracranial pressure can be observed, along with risk factors for post-operative paediatric cerebellar mutism syndrome or epilepsy. MRI can also identify complications of surgery or radiotherapy and monitor treatment response. Advanced imaging sequences provide valuable information about tumour and brain physiology, but clinical use is limited by extended scanning times and difficulties in processing and analysis. Brain eloquence classifications exist, but focus on adults with neurological deficits and are outdated. For the analysis of childhood tumours, limited numbers within tumour subgroups and the investigation of long-term outcomes necessitate using historical scans and/or multi-site collaboration. Variable imaging quality and differing acquisition parameters limit the use of segmentation algorithms and radiomic analysis. Harmonisation can standardise imaging in collaborative research, but can be challenging, while data-sharing produces further logistical challenges. Consequently, most research consists of small single-centre studies limited to regional analyses of tumour location. Technological advances reducing scanning times increase the feasibility of clinical acquisition of high-resolution standardised imaging including advanced physiological sequences. The RAPNO and SIOPE paediatric brain tumour imaging guidelines have improved image standardisation, which will benefit future collaborative imaging research. Modern machine learning techniques provide more nuanced approaches for integration and analysis of the complex and multifactorial data involved in cognitive outcome prediction.
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Affiliation(s)
- Simon Dockrell
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester M13 9PL, UK;
- Children’s Brain Tumour Research Network, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK; (I.K.-A.); (J.-P.K.)
- The Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Foundation Trust, Salford M6 8FJ, UK;
| | - Martin G. McCabe
- The Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Foundation Trust, Salford M6 8FJ, UK;
- The Christie NHS Foundation Trust, Manchester M0 4BX, UK
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Ian Kamaly-Asl
- Children’s Brain Tumour Research Network, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK; (I.K.-A.); (J.-P.K.)
- The Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Foundation Trust, Salford M6 8FJ, UK;
| | - John-Paul Kilday
- Children’s Brain Tumour Research Network, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK; (I.K.-A.); (J.-P.K.)
- The Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Foundation Trust, Salford M6 8FJ, UK;
- Division of Cancer Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Stavros M. Stivaros
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester M13 9PL, UK;
- Children’s Brain Tumour Research Network, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK; (I.K.-A.); (J.-P.K.)
- The Geoffrey Jefferson Brain Research Centre, Northern Care Alliance NHS Foundation Trust, Salford M6 8FJ, UK;
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25
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Mansour MA, Mostafa HN. Unmasking a Rare Venous-Predominant Arteriovenous Malformation: A Case of Recurrent Subarachnoid Hemorrhage Successfully Treated With Stereotactic Radiosurgery. Cureus 2025; 17:e80265. [PMID: 40196071 PMCID: PMC11975457 DOI: 10.7759/cureus.80265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2025] [Indexed: 04/09/2025] Open
Abstract
Arteriovenous malformations (AVMs) are a leading cause of intracranial hemorrhage in young adults, yet venous-predominant AVMs remain exceedingly rare and diagnostically challenging, often mimicking benign developmental venous anomalies (DVAs). We present the case of an 18-year-old male who suffered from recurrent subarachnoid hemorrhages due to a venous-predominant AVM initially misidentified as a DVA. Given the lesion's deep location and high surgical risk, stereotactic radiosurgery (SRS) was selected as the primary treatment modality. Over a 64-month follow-up, the patient demonstrated progressive obliteration of the AVM, culminating in complete resolution on conventional angiography at 55 months post-SRS. This case underscores the critical role of advanced imaging in distinguishing rare AVM subtypes, the importance of multidisciplinary decision-making, and the long-term efficacy of SRS in managing high-risk vascular lesions.
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Affiliation(s)
| | - Hamdi N Mostafa
- Neurosurgery, Nasser Institute for Research and Treatment, Cairo, EGY
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26
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Tos SM, Osama M, Mantziaris G, Hajikarimloo B, Adeeb N, Kandregula S, Dmytriw AA, Salim HA, Musmar B, Naamani KE, Ogilvy C, Kondziolka D, Abdelsalam A, Kumbhare D, Gummadi S, Ataoglu C, Erginoglu U, Essibayi MA, Keles A, Muram S, Sconzo D, Riina H, Rezai A, Pöppe J, Sen RD, Alwakaa O, Griessenauer CJ, Jabbour P, Tjoumakaris SI, Burkhardt JK, Starke RM, Baskaya M, Sekhar LN, Levitt MR, Altschul DJ, Haranhalli N, McAvoy M, Aslan A, Abushehab A, Swaid C, Abla A, Stapleton C, Koch M, Srinivasan VM, Chen PR, Blackburn S, Dannenbaum MJ, Choudhri O, Pukenas B, Orbach D, Smith E, Möhlenbruch M, Alaraj A, Aziz-Sultan A, Patel AB, Cuellar HH, Lawton M, Morcos J, Guthikonda B, Sheehan J. Spetzler-Martin grade I and II cerebral arteriovenous malformations: a propensity-score matched analysis of resection and stereotactic radiosurgery in adult patients. Neurosurg Rev 2025; 48:276. [PMID: 40016553 PMCID: PMC11868255 DOI: 10.1007/s10143-025-03431-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 02/13/2025] [Accepted: 02/20/2025] [Indexed: 03/01/2025]
Abstract
Cerebral arteriovenous malformations (AVMs) are congenital vascular anomalies that can lead to severe complications, including hemorrhage and neurological deficits. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) for SM grade I and II AVMs. Out of a large multicenter registry, we identified 180 matched patients with SM grade I and II AVMs treated with either microsurgical resection or SRS between 2010 and 2023. The primary outcomes were AVM obliteration rates and complications; secondary outcomes included neurological status and functional outcomes measured by the modified Rankin Scale (mRS). Propensity score matching (PSM) was utilized to ensure comparability between treatment groups. After PSM, 90 patients were allocated to each treatment group. Significant differences were observed in complete obliteration rates, with resection achieving higher rates compared to SRS in overall cases (97.8% vs. 60.0%, p < 0.001), unruptured AVMs (100% vs. 58.3%, p < 0.001), and ruptured AVMs (95.2% vs. 61.9%, p < 0.001). Functional improvement rates were similar between the groups for overall cases (67.2% in resection vs. 66.7% in SRS, p = 0.95), unruptured AVMs (55.2% in resection vs. 55.6% in SRS, p > 0.9), and ruptured AVMs (78.1% in resection vs. 74.1% in SRS, p = 0.7). Symptomatic complication rates were identical between the groups (11.1% each, p > 0.9), while permanent complication rates were comparable (6.7% in resection vs. 5.6% in SRS, p = 0.8). Resection demonstrated significantly higher complete obliteration rates compared to SRS across all cases, including unruptured and ruptured AVMs. Functional improvement rates were similar between the two treatment groups, with no significant differences in symptomatic or permanent complication rates.
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Affiliation(s)
- Salem M Tos
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Mahmoud Osama
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Georgios Mantziaris
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Bardia Hajikarimloo
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Sandeep Kandregula
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hamza Adel Salim
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Basel Musmar
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Sanjeev Gummadi
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Cagdas Ataoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Ufuk Erginoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Muhammed Amir Essibayi
- Montefiore Einstein Cerebrovascular Research Laband, Department of Neurological Surgery, Montefiore Medical Centeraq, Albert Einstein College of Medicine, New York, NY, USA
| | - Abdullah Keles
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Sandeep Muram
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Sconzo
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Howard Riina
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Arwin Rezai
- Department of Neurosurgery, Paracelsus Medical University, Christian Doppler Klinik, Salzburg, Austria
| | - Johannes Pöppe
- Department of Neurosurgery, Paracelsus Medical University, Christian Doppler Klinik, Salzburg, Austria
| | - Rajeev D Sen
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Omar Alwakaa
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Paracelsus Medical University, Christian Doppler Klinik, Salzburg, Austria
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Jan-Karl Burkhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Mustafa Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Laligam N Sekhar
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - David J Altschul
- Montefiore Einstein Cerebrovascular Research Laband, Department of Neurological Surgery, Montefiore Medical Centeraq, Albert Einstein College of Medicine, New York, NY, USA
| | - Neil Haranhalli
- Montefiore Einstein Cerebrovascular Research Laband, Department of Neurological Surgery, Montefiore Medical Centeraq, Albert Einstein College of Medicine, New York, NY, USA
| | - Malia McAvoy
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Assala Aslan
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | | | - Christian Swaid
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Adib Abla
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Christopher Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Visish M Srinivasan
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Peng R Chen
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Mark J Dannenbaum
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Omar Choudhri
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bryan Pukenas
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Markus Möhlenbruch
- Interventional Neuroradiology, Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinoisinaq, Chicago, IL, USA
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Hugo H Cuellar
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Michael Lawton
- Department of Neurosurgery, Barrow, Neurological Institute, Phoenix, AZ, USA
| | - Jacques Morcos
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, McGovern Medical School, UT Health Sciences Center at Houston, Houston, TX, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
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27
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Naser PV, Zacharias F, Giese H, Krieg SM, Unterberg AW, Younsi A. Patient-specific titanium-reinforced calcium-phosphate (CaP: Ti) implants for revision cranioplasty. BRAIN & SPINE 2025; 5:104213. [PMID: 40093034 PMCID: PMC11910373 DOI: 10.1016/j.bas.2025.104213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 12/01/2024] [Accepted: 02/12/2025] [Indexed: 03/19/2025]
Abstract
Introduction Cranioplasty is a common neurosurgical procedure, but infections can complicate it, necessitating revision surgery. Alloplastic patient-specific implants (PSI) are increasingly utilized, and different materials are available. This study evaluates the role of titanium-reinforced calcium-phosphate (CaP:Ti) implants in revision cranioplasty. Research question Assessing the efficacy and safety of CaP:Ti PSI in patients requiring revision cranioplasty following complications with previously failed cranioplasty attempts. Material and methods Retrospective analysis of 15 patients who underwent CaP:Ti PSI implantation for revision cranioplasty between 2016 and 2022 at a single neurosurgical department. Data on demographics, perioperative details, and outcomes were collected and assessed. Differences in distribution were assessed using Fisher's exact test, and groups were numerically compared using student's t-test. A p-value <0.05 was considered statistically significant. Results In most patients, CP failure occurred early (38 days) following elective craniotomy for tumor and vascular procedures. The first revision cranioplasty was conducted in 12 cases using CaP:Ti PSI in 8 cases successfully requiring no further revision. Three cases implanted with other alloplastic materials required revision and received CaP:Ti PSI in the second (n = 2) or third (n = 1) CP attempt. The overall success rate for CaP:Ti PSI was 73.3% over more than two years of follow-up. success rate in revision cranioplasty. Surgical site complications, predominantly infections, were the main cause of CP failure. The average interval between implant removal and re-cranioplasty was 300 days. Prehabilitation using skin expanders and postoperative antibiotic use were strategies successfully utilized in this cohort. Discussion and conclusion Our findings suggest that CaP:Ti PSI implants hold promise in salvaging complicated cranioplasty in most cases despite challenges such as infection and implant failure. The use of techniques like skin expanders may contribute to better outcomes. However, further research is crucial to establish optimal timing and patient selection guidelines in revision cranioplasty using CaP:Ti implants, which could significantly impact future neurosurgical practices.
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Affiliation(s)
- Paul Vincent Naser
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
- Heidelberg University Hospital, Division of Stereotactic Neurosurgery, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- AI Health Innovation Cluster, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Friederike Zacharias
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
| | - Henrik Giese
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
- Department of Neurosurgery, Academic Hospital Braunschweig, Salzdahlumer Straße 90, 38126, Braunschweig, Germany
| | - Sandro M. Krieg
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
| | - Andreas W. Unterberg
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
| | - Alexander Younsi
- Heidelberg University Hospital, Department of Neurosurgery, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg University, Medical Faculty, Grabengasse 1, 69117, Heidelberg, Germany
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28
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Musmar B, Adeeb N, Abdalrazeq H, Salim HA, Roy JM, Aslan A, Tjoumakaris SI, Ogilvy CS, Baskaya MK, Kondziolka D, Sheehan J, Riina H, Kandregula S, Dmytriw AA, Abushehab A, El Naamani K, Abdelsalam A, Ironside N, Kumbhare D, Gummadi S, Ataoglu C, Essibayi MA, Keles A, Muram S, Sconzo D, Rezai A, Alwakaa O, Tos SM, Mantziaris G, Park MS, Hanalioglu S, Erginoglu U, Pöppe J, Sen RD, Griessenauer CJ, Burkhardt JK, Starke RM, Sekhar LN, Levitt MR, Altschul DJ, Haranhalli N, McAvoy M, Zeineddine HA, Abla AA, Atallah E, Gooch MR, Rosenwasser RH, Stapleton C, Koch M, Srinivasan VM, Chen PR, Blackburn S, Bulsara K, Kim LJ, Choudhri O, Pukenas B, Smith E, Mosimann PJ, Alaraj A, Aziz-Sultan MA, Patel AB, Savardekar A, Notarianni C, Cuellar HH, Lawton M, Guthikonda B, Morcos J, Jabbour P. Comparative outcomes of arteriovenous malformations treatment in eloquent versus non-eloquent brain: A multicenter study with propensity-score weighting. Int J Stroke 2025:17474930251323503. [PMID: 39948730 DOI: 10.1177/17474930251323503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2025]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are complex vascular anomalies with a high risk of hemorrhage and neurological deficits, especially when located in eloquent brain regions. The eloquence of an AVM location is a critical factor in the treatment planning, influencing both the risk of complications and long-term functional outcomes. This study aims to compare outcomes between eloquent and non-eloquent AVMs. METHODS This multicenter, retrospective study utilized data from the Multicenter International Study for Treatment of Brain AVMs (MISTA) consortium. Patients with eloquent and non-eloquent AVMs were compared on baseline characteristics, angiographic outcomes, and functional outcomes using the modified Rankin Scale (mRS). Propensity score weighting (IPTW) was applied to adjust for confounding variables. RESULTS The study included 1013 patients, with 498 (49.2%) AVMs located in eloquent regions and 515 (50.8%) in non-eloquent regions. In unadjusted analysis, eloquent AVMs had lower complete obliteration rates (67.6% vs 79.5%, OR: 0.53, 95% CI: 0.39-0.72, p < 0.001) and higher complication rates (24.5% vs 19.0%, OR: 1.38, 95% CI: 1.02-1.86, p = 0.03) compared to non-eloquent AVMs. After IPTW adjustment, eloquent AVMs continued to show significantly higher odds of overall complications (OR: 1.68, 95% CI: 1.12-2.52, p = 0.01) and symptomatic complications (OR: 1.77, 95% CI: 1.12-2.80, p = 0.01). Secondary analysis within the eloquent group indicated that embolization was linked to an elevated risk of complications. Surgery and radiosurgery showed comparable functional outcomes at last follow-up and complications rates with higher complete obliteration rates in surgery. CONCLUSION AVMs in eloquent brain areas present higher risks of complications and lower obliteration rates, emphasizing the need for cautious, individualized treatment planning. Within the eloquent group, embolization increased the risk of complications, while surgery and radiosurgery showed comparable functional outcomes at last follow-up and complication rates with higher complete obliteration rates in surgery. These findings highlight the importance of location in AVM management and support further research focusing on comparing treatment strategies for AVMs in eloquent brain areas.
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Affiliation(s)
- Basel Musmar
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nimer Adeeb
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Hammam Abdalrazeq
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Hamza Adel Salim
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Joanna M Roy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Assala Aslan
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | | | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Howard Riina
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Sanjeev Gummadi
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Cagdas Ataoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Muhammed Amir Essibayi
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Abdullah Keles
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Sandeep Muram
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Sconzo
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arwin Rezai
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Omar Alwakaa
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Salem M Tos
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Georgios Mantziaris
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Sahin Hanalioglu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ufuk Erginoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Johannes Pöppe
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Rajeev D Sen
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Starke
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laligam N Sekhar
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - David J Altschul
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Neil Haranhalli
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Malia McAvoy
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Hussein A Zeineddine
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Adib A Abla
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Peng R Chen
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ketan Bulsara
- Department of Neurosurgery, University of Connecticut, Mansfield, CT, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Omar Choudhri
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Smith
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal J Mosimann
- Division of Interventional and Diagnostic Neuroradiology, Department of Radiology, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Mohammad A Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amey Savardekar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Christina Notarianni
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Hugo H Cuellar
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Michael Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Jacques Morcos
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Shah HA, Duehr J, Abramyan A, Mittelman L, Galvez R, Winby T, Silverstein JW, D'Amico RS. Enhancing brain tumor surgery precision with multimodal connectome imaging: Structural and functional connectivity in language-dominant areas. Clin Neurol Neurosurg 2025; 249:108760. [PMID: 39870028 DOI: 10.1016/j.clineuro.2025.108760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Accepted: 01/23/2025] [Indexed: 01/29/2025]
Abstract
OBJECTIVES Language is a critical aspect of human cognition and function, and its preservation is a priority for neurosurgical interventions in the left frontal operculum. However, identification of language areas can be inconsistent, even with electrical mapping. The use of multimodal structural and functional neuroimaging in conjunction with intraoperative neuromonitoring may augment cortical language area identification to guide the resection of left frontal opercular lesions. METHODS Structural and functional connectome scans were generated using a machine learning software to reparcellate a validated schema of the Human Connectome Project Multi-Modal Parcellation (HCP-MMP) atlas based on individual structural and functional connectivity identified through anatomic, diffusion, and resting-state functional MRI (rs-fMRI). Structural connectivity imaging was analyzed to determine at-risk parcellations and seed-based analysis of regions of interest (ROIs) was performed to identify functional relationships. RESULTS Two patients with left frontal lesions were analyzed, one with a WHO Grade IV gliosarcoma, and the other with an intracerebral abscess. Individual patterns of functional connectivity were identified by functional neuroimaging revealing distinct relationships between language network parcellations. Multimodal, connectome-guided resections with intraoperative neuromonitoring were performed, with both patients demonstrating intact or improved language function relative to baseline at follow-up. Follow-up imaging demonstrated functional reorganization observed between Brodmann areas 44 and 45 and other parcellations of the language network. CONCLUSION Preoperative visualization of structural and functional connectivity of language areas can be incorporated into a multimodal operative approach with intraoperative neuromonitoring to facilitate the preservation of language areas during intracranial neurosurgery. These modalities may also be used to monitor functional recovery.
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Affiliation(s)
- Harshal A Shah
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
| | - James Duehr
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Arevik Abramyan
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Laura Mittelman
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Rosivel Galvez
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Downstate Medical Center, State University of New York, New York, NY, USA
| | - Taylor Winby
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA; Neuro Protective Solutions, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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30
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Morris D, Williams JR, Vangelov B, Smee RI. Arteriovenous malformations treated by stereotactic radiosurgery - Review of an Australian single centre's experience. J Clin Neurosci 2025; 132:110961. [PMID: 39652987 DOI: 10.1016/j.jocn.2024.110961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 12/01/2024] [Accepted: 12/02/2024] [Indexed: 01/28/2025]
Abstract
Linear accelerator (LINAC) stereotactic radiosurgery (SRS) is a specialised treatment used for various brain conditions, including arteriovenous malformations (AVMs). This paper investigates the obliteration rate of AVMs treated by the LINAC-based facility at Prince of Wales Hospital, defines factors influencing obliteration rate, time to obliteration and complications post-SRS. A retrospective audit review of patient notes sourced from electronic medical records was conducted. During the study period 219 patients received treatment, of which the final status of 136 AVMs was known. Overall obliteration rate was 75.7 %, with obliteration rates of 5 %, 30 % and 46 % at one, three and four years, respectively. Post analysis, a radiosurgery dose of ≥ 18 Gray (Gy) was predictive of achieving obliteration (Odds Ratio (OR) 4.2, 95 % Confidence Interval (CI) 1.61-10.83, p = 0.003) whilst a nidus size of 3-6 cm was less likely of achieving obliteration (OR 0.2, CI 0.10-0.57, p = 0.001). Multivariate analysis showed a radiosurgery dose of ≥ 18 Gy remained predictive (OR 4.7, CI 1.69-13.25, p = 0.003) and a nidus size of 3-6 cm remained less likely to achieve obliteration (OR 0.2, CI 0.10-0.57, p = 0.001). Females were predictive of developing temporary complications post-SRS in multivariate analysis (OR 2.8, CI 1.24-6.13, p = 0.013), and having > 1 SRS session was predictive of developing permanent complications post-SRS (OR 7.1, CI 2.44-20.53, p < 0.001). The obliteration rate achieved from our study and the predictive nature to achieve obliteration with a radiosurgery dose of ≥ 18 Gy is comparable to existing literature including that using the Gamma-Knife system.
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Affiliation(s)
- Daniel Morris
- University of New South Wales, Faculty of Medicine and Health, Randwick, NSW 2031, Australia
| | - Janet R Williams
- Department of Radiation Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, 2031 New South Wales, Australia; School of Clinical Medicine (Randwick Campus), Faculty of Medicine and Health, University of New South Wales, Randwick, 2031 New South Wales, Australia.
| | - Belinda Vangelov
- Department of Radiation Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, 2031 New South Wales, Australia
| | - Robert I Smee
- Department of Radiation Oncology, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, 2031 New South Wales, Australia; School of Clinical Medicine (Randwick Campus), Faculty of Medicine and Health, University of New South Wales, Randwick, 2031 New South Wales, Australia; Department of Radiation Oncology, Tamworth Base Hospital, Tamworth, 2340 New South Wales, Australia
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31
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Pohjola A, Vest T, Verho L, Aarnio K, Rantanen K, Laivuori H, Gissler M, Laakso A, Niemelä M, Ijäs P. Intracranial Arteriovenous Malformations During Pregnancy and Puerperium-A Retrospective Nationwide Population-Based Cohort Study. Neurosurgery 2025; 96:346-355. [PMID: 38934658 PMCID: PMC11698266 DOI: 10.1227/neu.0000000000003067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The knowledge about the management of patients with brain arteriovenous malformations (AVM) during pregnancy is limited, owing partly to insufficient evidence about the outcomes of newborns. This study aims to explore symptomatic AVMs and their outcomes during pregnancy, delivery, and the postpartum period. METHODS We conducted a retrospective analysis by combining patients with symptomatic AVM from a nationwide population-based cohort of all women with a pregnancy resulting in delivery during 1987 to 2016 (n = 1 773 728 deliveries) and our AVM database (n = 805, 1942-2014). Cerebrovascular events during pregnancy were identified through International Classification of Diseases-9, International Classification of Diseases-10, or surgical procedure codes from the Hospital Discharge and Medical Birth Registers. Our analysis focused on treatment characteristics and outcomes of patients with AVM hemorrhage or symptomatic AVM during pregnancy, delivery, or puerperium. RESULTS A total of 28 women with symptomatic AVMs during pregnancy, delivery, or postpartum period were followed for an average of 12.8 years (SD = 15.5) after admission. Among them, 21 (75%) experienced AVM hemorrhages during pregnancy, puerperium, or delivery. The mean age of patients was 28.9 years (SD = 5.5). Hemorrhages occurred predominantly during the second (n = 9, 43% of all ruptures) or the third trimester (n = 5, 24%). Two AVM ruptures occurred during labor. Treatment for AVM took place during pregnancy (n = 7, 25%) or puerperium (n = 3, 14%) in 10 patients (35.7%). Only 5 mothers (17.8%) had not been previously pregnant. There was no significant difference in mean Apgar scores between those with AVM hemorrhage (8.3) and those without (8.4). CONCLUSION Most mothers in the study had prior pregnancies, suggesting a potentially weaker association between AVM rupture and pregnancy compared to previous reports. Notably, 2 AVM ruptures occurred during spontaneous vaginal deliveries. Outcomes were generally favorable in both mothers and infants. More research is needed to refine our understanding of the optimal timing for invasive treatment during pregnancy.
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Affiliation(s)
- Anni Pohjola
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Teresa Vest
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Liisa Verho
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kirsi Rantanen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research Tampere, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Maruyama D, Iida H, Koshino K, Nakagawara J, Morita Y, Hashimura N, Mori H, Satow T, Takahashi JC, Fukuda T, Iihara K, Kataoka H. Comparative analysis of peri-nidal cerebral blood flow and metabolism using a novel quantitative 15O-PET method in patients with arteriovenous malformations. J Cereb Blood Flow Metab 2025; 45:259-274. [PMID: 39129183 PMCID: PMC11800276 DOI: 10.1177/0271678x241270416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024]
Abstract
To effectively treat cerebral arteriovenous malformations (AVMs), peri-nidal flow regulation and metabolic status must be understood. In this study, we used 15O-oxygen positron emission tomography (PET) post-processing analysis to investigate vascular radioactivity in the nidal region of AVMs. Single-dynamic PET imaging was performed on seven unruptured AVM patients during the sequential inhalation of 15O2 and C15O2. A previously validated dual-tracer basis function method (DBFM) was employed to calculate parametric images. The results of our study were as follows. First, in remote and contralateral AVM regions, DBFM and a previous approach of dual-tracer autoradiography (DARG) showed strong positive correlations in cerebral blood flow (CBF), cerebral oxygen metabolism rate (CMRO2), and oxygen extraction fraction. Second, peri-nidal CBF and CMRO2 correlation was lower, and overestimation occurred with DARG compared to with DBFM. Third, on comparing DBFM to quantitative 123I-iodoamphetamine single-photon emission computed tomography (SPECT), CBF correlated significantly. In contrast, the correlation between DARG and quantitative 123I-iodoamphetamine-SPECT was weaker in the peri-nidal regions. Fourth, analysis of tissue time-activity curves demonstrated good reproducibility using the novel formulation in the control, peri-nidus, and core nidal regions, indicating the adequacy of this approach. Overall, the DBFM approach holds promise for assessing haemodynamic alterations in patients with AVMs.
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Affiliation(s)
- Daisuke Maruyama
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hidehiro Iida
- Turku PET Centre, University of Turku, Turku, Finland
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuhiro Koshino
- Department of Investigative Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jyoji Nakagawara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naoki Hashimura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Graffeo CS, Kotecha R, Sahgal A, Fariselli L, Gorgulho A, Levivier M, Ma L, Paddick I, Regis J, Sheehan JP, Suh JH, Yomo S, Pollock BE. Stereotactic Radiosurgery for Intermediate (III) or High (IV-V) Spetzler-Martin Grade Arteriovenous Malformations: International Stereotactic Radiosurgery Society Practice Guideline. Neurosurgery 2025; 96:298-307. [PMID: 38989995 DOI: 10.1227/neu.0000000000003102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/29/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Consensus guidelines do not exist to guide the role of stereotactic radiosurgery (SRS) in the management of patients with Spetzler-Martin Grade III-V arteriovenous malformations (AVMs). We sought to establish SRS practice guidelines for Grade III-V AVMs based on a critical systematic review of the published literature. METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant search of Medline, Embase, and Scopus, 1986 to 2023, for publications reporting post-SRS outcomes in ≥10 Grade III-V AVMs with the median follow-up ≥24 months was performed. Primary end points were AVM obliteration and post-SRS hemorrhage. Secondary end points included dosimetric variables, Spetzler-Martin parameters, and neurological outcome. RESULTS : In total, 2463 abstracts were screened, 196 manuscripts were reviewed, and 9 met the strict inclusion criteria. The overall sample of 1634 AVMs consisted of 1431 Grade III (88%), 186 Grade IV (11%), and 11 Grade V lesions (1%). Total median post-SRS follow-up was 53 months for Grade III and 43 months for Grade IV-V AVMs (ranges, 2-290; 12-262). For Grade III AVMs, the crude obliteration rate was 72%, and among Grade IV-V lesions, the crude obliteration rate was 46%. Post-SRS hemorrhage was observed in 7% of Grade III compared with 17% of Grade IV-V lesions. Major permanent deficits or death from hemorrhage or radiation-induced complications occurred in 86 Grade III (6%) and 22 Grade IV-V AVMs (12%). CONCLUSION Most patients with Spetzler-Martin Grade III AVMs have favorable SRS treatment outcomes; however, the obliteration rate for Grade IV-V AVMs is less than 50%. The available studies are heterogenous and lack nuanced, long-term, grade-specific outcomes.
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Affiliation(s)
- Christopher S Graffeo
- Department of Neurological Surgery, University of Oklahoma, Oklahoma City , Oklahoma , USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami , Florida , USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto , Ontario , Canada
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico C Besta, Milan , Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo , Brazil
- D'Or Institute for Research and Education, São Paulo , Brazil
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne , Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of Southern California, Los Angeles , California , USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London , UK
| | - Jean Regis
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut de Neurosciences des Systèmes (INS) UMR1106, Marseille , France
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland , Ohio , USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto , Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
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Shah HA, Mittelman L, Singha S, Galvez R, Cavallaro J, Yaffe B, Huang G, Silverstein JW, D'Amico RS. Connectome imaging to facilitate preservation of the frontal aslant tract. Clin Neurol Neurosurg 2025; 249:108726. [PMID: 39778391 DOI: 10.1016/j.clineuro.2025.108726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2025] [Accepted: 01/04/2025] [Indexed: 01/11/2025]
Abstract
Supplementary motor area (SMA) syndrome is characterized by contralateral akinesia and mutism, and frequently occurs following resection of tumors involving the superior frontal gyrus. The frontal aslant tract (FAT), involved in functional connectivity of the supplementary area and other related large-scale brain networks, is implicated in the pathogenesis of, and recovery from, SMA syndrome. However, intraoperative neuromonitoring of the FAT is inconsistent and poorly reproducible, leading to a high rate of postoperative SMA syndrome. We report the cases of two patients harboring lesions of the superior frontal gyrus: one cavernoma and one low grade glioma. Connectome imaging revealed involvement of functional networks implicated in SMA syndrome, as well as displacement of the FAT. A connectome-guided awake craniotomy was performed in both cases, and a combinatorial approach using awake language mapping and connectome-imaging guidance facilitated gross total resection of both patient's lesions without inducing SMA syndrome postoperatively. Functional and structural connectivity imaging through connectomics allows the identification of areas not traditionally considered eloquent, such as the SMA and FAT, and can help facilitate their preservation. Conserving the functional and structural connectivity of broader brain regions that are not traditionally deemed eloquent can improve patient outcomes.
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Affiliation(s)
- Harshal A Shah
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
| | - Laura Mittelman
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Souvik Singha
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Rosivel Galvez
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Julianna Cavallaro
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Beril Yaffe
- Department of Neurology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Grace Huang
- Neuro Protective Solutions, New York, NY, USA
| | - Justin W Silverstein
- Department of Neurology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA; Neuro Protective Solutions, New York, NY, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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35
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Davison M, McCune M, Thiyagarajah N, Kashkoush A, Achey R, Shost M, Toth G, Bain M, Moore N. The incidence of infratentorial arteriovenous malformation-associated aneurysms: an institutional case series and systematic literature review. J Neurointerv Surg 2025:jnis-2024-022003. [PMID: 38937081 DOI: 10.1136/jnis-2024-022003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Arteriovenous malformation (AVM)-associated aneurysms represent a high-risk feature predisposing them to rupture. Infratentorial AVMs have been shown to have a greater incidence of associated aneurysms, however the existing data is outdated and biased. The aim of our research was to compare the incidence of supratentorial vs infratentorial AVM-associated aneurysms. METHODS Patients were identified from our institutional AVM registry, which includes all patients with an intracranial AVM diagnosis since 2000, regardless of treatment. Records were reviewed for clinical details, AVM characteristics, nidus location (supratentorial or infratentorial), and presence of associated aneurysms. Statistical comparisons were made using Fisher's exact or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis determined independent predictors of AVM-associated aneurysms. As a secondary analysis, a systematic literature review was performed, where studies documenting the incidence of AVM-associated aneurysms stratified by location were of interest. RESULTS From 2000-2024, 706 patients with 720 AVMs were identified, of which 152 (21.1%) were infratentorial. Intracranial hemorrhage was the most common AVM presentation (42.1%). The incidence of associated aneurysms was greater in infratentorial AVMs compared with supratentorial cases (45.4% vs 20.1%; P<0.0001). Multivariable logistic regression demonstrated that infratentorial nidus location was the singular predictor of an associated aneurysm, odds ratio: 2.9 (P<0.0001). Systematic literature review identified eight studies satisfying inclusion criteria. Aggregate analysis indicated infratentorial AVMs were more likely to harbor an associated aneurysm (OR 1.7) and present as ruptured (OR 3.9), P<0.0001. CONCLUSIONS In this modern consecutive patient series, infratentorial nidus location was a significant predictor of an associated aneurysm and hemorrhagic presentation.
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Affiliation(s)
- Mark Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Maximos McCune
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | | | - Ahmed Kashkoush
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Shost
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Nina Moore
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
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Baptista VS, da Silva EB, de Oliveira Bianchi JS, Jong-A-Liem GS, de Souza Coelho D, Wuo-Silva R, Chaddad-Neto F. Analysis of the incidence of death, hemorrhage, and neurological deficit in the treatment of intracranial arteriovenous malformations (AVMs): surgery versus other treatments - a systematic review. Neurosurg Rev 2025; 48:51. [PMID: 39812905 DOI: 10.1007/s10143-025-03200-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 12/04/2024] [Accepted: 01/04/2025] [Indexed: 01/16/2025]
Abstract
To evaluate the incidence of mortality, hemorrhage, and neurological deficits in treating intracranial arteriovenous malformations (AVMs) in patients over 18 through a comparative analysis of surgical approaches and other therapeutic modalities. A systematic review was conducted using MEDLINE, Embase, CENTRAL, and LILACS databases in November 2023. Inclusion criteria included clinical trials, cohorts studies, case-controls studies, and case series comparing patients over 18 undergoing surgery or microsurgery versus other treatments (radiosurgery, isolated embolization, and conservative treatment). Exclusions criteria included studies on non-AVM diseases, non-intracranial AVMs, cavernous malformations, pregnant patients, and those treated with both radiosurgery and microsurgery. Twelve studies included 1,555 patients, with an average age of 42.65 years. Of these, 711 underwent surgery (with or without prior embolization), and 844 underwent other procedures. In the surgery group, the incidence of death was 1.69%, while in the other procedures group, it was 2.96%. The incidence of neurological deficits and hemorrhage in the surgery group was 11.67% and 4.22%, respectively. In other procedures, these incidences were both 9.12%. The average obliteration rate in the surgery group was 97.45%, compared to 49.77% for radiosurgery, 38.46% for isolated embolization, and 0.6% for conservative treatment. This systematic review highlighs that surgery achieves the highest AVM obliteration rates but carries a higher risk neurological déficits. Radiosurgery minimizes these risks, while conservative treatment offers advantages in mortality and hemorrhage reduction. No single modality proves to be universally superior, emphasizing the need for personalized approaches and further randomized trials to clarify comparative safety and efficacy.
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Affiliation(s)
- Vinicius Santos Baptista
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Erik Basbasque da Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Daniela de Souza Coelho
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Raphael Wuo-Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil.
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Orscelik A, Musmar B, Matsukawa H, Ismail M, Elawady SS, Assad S, Cunningham C, Sowlat MM, Spiotta AM. Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2025; 96:18-28. [PMID: 38912816 DOI: 10.1227/neu.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). METHOD Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. RESULTS MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). CONCLUSION This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.
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Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Mustafa Ismail
- College of Medicine, University of Baghdad, Baghdad , Iraq
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Salman Assad
- Department of Neurology, University of Nebraska Medical Center, Omaha , Nebraska , USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
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Jabarkheel R, Li L, Frankfurter M, Zhang DY, Gajjar A, Muhammad N, Srinivasan VM, Burkhardt JK, Kahn M. Untangling sporadic brain arteriovenous malformations: towards targeting the KRAS/MAPK pathway. Front Surg 2024; 11:1504612. [PMID: 39687326 PMCID: PMC11646853 DOI: 10.3389/fsurg.2024.1504612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 10/30/2024] [Indexed: 12/18/2024] Open
Abstract
Brain arteriovenous malformations (AVMs) are vascular lesions characterized by abnormal connections between parenchymal arteries and veins, bypassing a capillary bed, and forming a nidus. Brain AVMs are consequential as they are prone to rupture and associated with significant morbidity. They can broadly be subdivided into hereditary vs. sporadic lesions with sporadic brain AVMs representing the majority of all brain AVMs. However, little had been known about the pathogenesis of sporadic brain AVMs until the landmark discovery in 2018 that the majority of sporadic brain AVMs carry somatic activating mutations of the oncogene, Kirsten rat sarcoma viral oncogene homologue (KRAS), in their endothelial cells. Here, we review the history of brain AVMs, their treatments, and recent advances in uncovering the pathogenesis of sporadic brain AVMs. We specifically focus on the latest studies suggesting that pharmacologically targeting the KRAS/MEK pathway may be a potentially efficacious treatment for sporadic brain AVMs.
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Affiliation(s)
- Rashad Jabarkheel
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States
| | - Lun Li
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States
| | - Maxwell Frankfurter
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel Y. Zhang
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Avi Gajjar
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Najib Muhammad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Visish M. Srinivasan
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Mark Kahn
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Department of Medicine and Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, United States
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Dabhi N, Sokolowski J, Zanaty M, Kellogg RT, Park MS, Mastorakos P. Primary Embolization of Cerebral Arteriovenous Malformations With Intention to Cure: A Systematic Review of Literature and Meta-Analysis. Neurosurgery 2024; 95:1232-1244. [PMID: 38842298 DOI: 10.1227/neu.0000000000003001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The treatment of brain arteriovenous malformations (AVMs) involves multiple approaches, including embolization, microsurgical resection, and radiosurgery. With the advent of new embolisates, dual-lumen balloon catheters, detachable tip microcatheters, and transvenous embolization, endovascular AVM obliteration has become more effective. Although adjuvant embolization and embolization are commonly used, the safety and effectiveness of curative embolization remain unclear. METHODS We conducted a systematic literature review using PubMed, Ovid Medline, and Web of Science to identify studies reporting outcomes in patients with AVMs who underwent primary embolization with the intention to cure. We collected data on patient characteristics, AVM features, complications, and radiographic and clinical outcomes for meta-analysis. RESULTS We identified 25 studies with a total of 1425 patients with 1427 AVMs who underwent curative embolization. Of these patients, 70% were low grade (pooled = 61% [39-82]), 67% were <3 cm (pooled = 78% [60-92]), and 75% were in superficial locations (pooled = 80% [72-86]). At last radiographic follow-up (mean, 16.7 ± 10.9 months), the full obliteration rate was 52% (pooled = 61% [43-77]) and retreatment rate was 25% (pooled = 17% [8.3-27]). At last clinical follow-up (mean, 24.2 ± 13.3 months), the poor clinical outcome rate was 7.9% (pooled = 4.4% [1.3-8.7]) and symptomatic complication rate was 13% (pooled = 13% [8-19]). There was no significant difference in the rate of radiographic cure, need for retreatment, and poor outcomes between ruptured and unruptured AVMs. Symptomatic complications were more common in the treatment of unruptured AVMs. The primary outcomes showed high heterogeneity (I 2 = 72%-94%). CONCLUSION Curative embolization of AVM is primarily reserved for small and low-grade AVMs, with highly variable outcomes. Our findings suggest poor radiographic outcomes and increased risk of complications. Outcomes are highly dependent on patient selection and technique used. Large multicenter prospective studies are required to further guide patient selection, categorize clinical and radiographic outcomes, and identify subgroup of patients that may benefit from curative embolization.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Jennifer Sokolowski
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City , Iowa , USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
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40
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Mansour MA, Malaeb RW, Mostafa HN, Kamal MI, Ayoub B. Diagnostic and therapeutic dilemmas of asymptomatic intracranial AVMs: A case report and evidence-based review. Radiol Case Rep 2024; 19:6452-6459. [PMID: 39380823 PMCID: PMC11460630 DOI: 10.1016/j.radcr.2024.08.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 10/10/2024] Open
Abstract
First described by Virchow in the 19th century, intracranial arteriovenous malformations (AVMs) are complex, tangle-shaped vascular lesions with a number of associated neuroparenchymal, hemodynamic, and angio-architectural changes. However, the clinical description of extracranial AVMs dates back to the Ebers Papyrus (c. 1500 BC), with a still unknown definitive underlying etiology thus far. AVMs are rare lesions, with approximately 0.15% incidence and 0.001-0.5% prevalence, but of high importance as they tend to affect young patients who are frequently otherwise healthy. In the majority of cases, AVMs present as sudden intracranial hemorrhages that require immediate intervention, but incidentally-detected unruptured AVMs are only found in ∼15% of cases, leaving a confusing dilemma regarding the appropriate next step, particularly given the several therapeutic interventions available and clinical trials that were vulnerable to follow-up criticism. Herein, we present a case of an incidentally detected asymptomatic AVM in a 15-year-old boy via advanced imaging techniques that was initially misinterpreted as a post-traumatic subarachnoid hemorrhage on routine imaging studies. In providing a comprehensive overview of pathological classification schemes and the currently available diagnostic options for these silent dilemmatic AVMs, we highlight three management techniques: microsurgical resection, endovascular embolization, and stereotactic surgery, with the best option depends mostly on addressing lesion resection properly with minimal associated mortality and morbidity.
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Affiliation(s)
- Moustafa A. Mansour
- Department of Neurosurgery, Nasser Institute for Research and Treatment, Cairo, Egypt
- Department of Neurology and Neurologic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Reem W. Malaeb
- Department of Health Professions, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hamdi Nabawi Mostafa
- Department of Neurosurgery, Nasser Institute for Research and Treatment, Cairo, Egypt
- Department of Neurosurgery, Misr University for Science and Technology, Giza, Egypt
| | - Mohamed Ibrahem Kamal
- Department of Neurosurgery, Nasser Institute for Research and Treatment, Cairo, Egypt
- Department of Neurosurgery, Al Bank Al Ahly Hospital for Integrated Care, Cairo, Egypt
- Department of Neurosurgery, El- Sahel Teaching Hospital, Cairo, Egypt
- Department of Neurosurgery, Ismailia Medical Complex Hospital, Ismailia, Egypt
| | - Basim Ayoub
- Department of Neurosurgery, Nasser Institute for Research and Treatment, Cairo, Egypt
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Neurosurgery, Kasr Al-Aini Hospital, Cairo, Egypt
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41
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Lu C, Han H, Ma L, Li R, Li Z, Zhang H, Yuan K, Zhang Y, Li A, Wang K, Zhao Y, Jin W, Gao D, Jin H, Meng X, Yan D, Li R, Lin F, Hao Q, Wang H, Ye X, Kang S, Pu J, Shi Z, Chao X, Lin Z, Lu J, Li Y, Zhao Y, Sun S, Chen X, Chen W, Chen Y, Wang S. Comparison of Long-Term Outcomes in Ruptured Diffuse Brain Arteriovenous Malformations Between Interventional Therapy and Conservative Management. Transl Stroke Res 2024; 15:1154-1164. [PMID: 37776489 DOI: 10.1007/s12975-023-01197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023]
Abstract
Brain arteriovenous malformations (AVMs) with a diffuse nidus structure present a therapeutic challenge due to their complexity and elevated risk of hemorrhagic events. This study examines the long-term effectiveness of interventional therapy versus conservative management in reducing hemorrhagic stroke or death in patients with ruptured diffuse AVMs. The analysis was conducted based on a multi-institutional database in China. Patients were divided into two groups: conservative management and interventional therapy. Using propensity score matching, patients were compared for the primary outcome of hemorrhagic stroke or death and the secondary outcomes of disability and neurofunctional decline. Out of 4286 consecutive AVMs in the registry, 901 patients were eligible. After matching, 70 pairs of patients remained with a median follow-up of 4.0 years. The conservative management group showed a trend toward higher rates of the primary outcome compared to the interventional group (4.15 vs. 1.87 per 100 patient-years, P = 0.090). While not statistically significant, intervention reduced the risk of hemorrhagic stroke or death by 55% (HR, 0.45 [95% CI 0.18-1.14], P = 0.094). No significant differences were observed in secondary outcomes of disability (OR, 0.89 [95% CI 0.35-2.26], P = 0.813) and neurofunctional decline (OR, 0.65 [95% CI 0.26 -1.63], P = 0.355). Subgroup analysis revealed particular benefits in interventional therapy for AVMs with a supplemented S-M grade of II-VI (HR, 0.10 [95% CI 0.01-0.79], P = 0.029). This study suggests a trend toward lower long-term hemorrhagic risks with intervention when compared to conservative management in ruptured diffuse AVMs, especially within supplemented S-M grade II-VI subgroups. No evidence indicated that interventional approaches worsen neurofunctional outcomes.
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Affiliation(s)
- Changyu Lu
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Pu
- First Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated to Nanjing University, Nanjing, Jiangsu, China
| | - Xiaofeng Chao
- Department of Neurosurgery, The Second Affiliated Hospital of Xuzhou Medical University, Jiangsu, China
| | - Zhengfeng Lin
- Department of Neurosurgery, The First People's Hospital of Qinzhou, Guangxi, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Weiwei Chen
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
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de Oliveira Souza NV, Lamiraux T, Vencato da Silva F, Lima VM, Rouchaud A, Saleme S, Mounayer C. Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale. Neurosurgery 2024; 95:1378-1387. [PMID: 38847513 DOI: 10.1227/neu.0000000000003016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/03/2024] [Indexed: 12/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Limited evidence exists for endovascular first-line treatment of Spetzler-Martin (SM) grade III brain arteriovenous malformations (AVMs). In this article, we sought to evaluate advanced endovascular techniques for treating SM III AVMs across different sizes, eloquence, and patterns of venous drainage. METHODS Data from AVMs SM III treated between January 2010 and January 2022 were collected: size (S), eloquence (E), drainage (V), angioarchitecture features (arterial and venous aneurysms, venous drainage, and venous stenosis), treatment strategy (single arterial, double arterial, venous, both arterial and venous, and transvenous endovascular embolization with selective temporary flow arrest [TFATVE]), neoadjuvant treatment, and number of previous embolization sessions. AVMs were classified according to the modified SM grade as follows: small (S1V1E1/III-), medium/deep (S2V1E0/III), medium/eloquent (S2V0E1/III+), and large (S3V0E0). Treatment complications (hemorrhagic and ischemic), clinical discharge and 6-month outcomes (modified Rankin Scale 0-2, mRS), and angiographic occlusion rates were recorded. RESULTS A total of 91 AVMs (62.6% ruptured, 72.5% S1V1E1, 7% S2V1E0, 19.7% S2V0E1, and 0% S3V0E0) in 91 patients (mean age 37 ± 15.8 years) were included. Treatment techniques included single arterial approach (28.6%), double arterial technique (30.8%), single venous strategy (9.9%), TFATVE (10.9%), and arterial and venous combined (19.8%). The angiographic occlusion rate was 91.2% (90.9% S1V1E1, 100% S2V1E0, and 88.9% S2V0E1) for all techniques, and 100% for the transvenous technique, isolated or combined with transarterial embolization. Minor complication (mRS 0-2), major complication (mRS >2), and mortality rate were 16.5%, 2.2%, and 3.4%, respectively. Overall, treatment morbimortality (mRS >2) was 3% (2/66) for S1V1E1, 0% for S2V1E0, and 16.7% (3/18) for S2V0E1. CONCLUSION Although morbidity is non-negligible , endovascular treatment of SM grade III lesions with advanced techniques offers up to 100% rates of cure, which is of high interest, especially for ruptured deep-seated eloquent AVMs with high reruptured rates, and less amenable to microsurgery techniques.
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Affiliation(s)
- Natália Vasconcellos de Oliveira Souza
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
- Neurovascular Centre, Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto , Ontario , Canada
- Department of Neurology, Hospital Israelita Albert Einstein, São Paulo , Brazil
- Department of Neurology and Neurosurgery, University of São Paulo, Sao Paulo , Brazil
| | - Tabata Lamiraux
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
| | - Felipe Vencato da Silva
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
| | - Vinicius Moreira Lima
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
| | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
- BioEMXLim, University of Limoges Medical Faculty, Limoges , France
| | - Suzana Saleme
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
| | - Charbel Mounayer
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges , France
- Department of Neurology and Neurosurgery, University of São Paulo, Sao Paulo , Brazil
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Saito S, Nakamura Y, Miyashita S, Sato T, Hoshina K, Okada M, Hasegawa H, Oishi M, Fujii Y, Körbelin J, Kubota Y, Tainaka K, Natsumeda M, Ueno M. CRISPR/CasRx suppresses KRAS-induced brain arteriovenous malformation developed in postnatal brain endothelial cells in mice. JCI Insight 2024; 9:e179729. [PMID: 39576014 PMCID: PMC11601911 DOI: 10.1172/jci.insight.179729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 10/02/2024] [Indexed: 11/29/2024] Open
Abstract
Brain arteriovenous malformations (bAVMs) are anomalies forming vascular tangles connecting the arteries and veins, which cause hemorrhagic stroke in young adults. Current surgical approaches are highly invasive, and alternative therapeutic methods are warranted. Recent genetic studies identified KRAS mutations in endothelial cells of bAVMs; however, the underlying process leading to malformation in the postnatal stage remains unknown. Here we established a mouse model of bAVM developing during the early postnatal stage. Among 4 methods tested, mutant KRAS specifically introduced in brain endothelial cells by brain endothelial cell-directed adeno-associated virus (AAV) and endothelial cell-specific Cdh5-CreERT2 mice successfully induced bAVMs in the postnatal period. Mutant KRAS led to the development of multiple vascular tangles and hemorrhage in the brain with increased MAPK/ERK signaling and growth in endothelial cells. Three-dimensional analyses in cleared tissue revealed dilated vascular networks connecting arteries and veins, similar to human bAVMs. Single-cell RNA-Seq revealed dysregulated gene expressions in endothelial cells and multiple cell types involved in the pathological process. Finally, we employed CRISPR/CasRx to knock down mutant KRAS expression, which efficiently suppressed bAVM development. The present model reveals pathological processes that lead to postnatal bAVMs and demonstrates the efficacy of therapeutic strategies with CRISPR/CasRx.
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Affiliation(s)
- Shoji Saito
- Department of Neurosurgery and
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | - Yuka Nakamura
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | - Satoshi Miyashita
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | - Tokiharu Sato
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | - Kana Hoshina
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | | | | | | | | | - Jakob Körbelin
- Department of Oncology, Hematology and Bone Marrow Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yoshiaki Kubota
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
| | - Kazuki Tainaka
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | | | - Masaki Ueno
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
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de Campos Filho JM, Lucifero AG, Ahumada-Vizcaíno JC, Mulato JEC, Marussi VHR, de Siqueira Campos CM, da Costa MDS, Dória-Netto HL, Wuo-Silva R, Chaddad-Neto F. Risk assessment for rupture of brain arteriovenous malformations using high-resolution black-blood magnetic resonance imaging: a single-center case series. Neurosurg Rev 2024; 47:840. [PMID: 39523229 DOI: 10.1007/s10143-024-03084-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 10/11/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Abstract
OBJECTIVE Chronic inflammation's role in the pathogenesis, development, and rupture of vascular malformations is undebated. Advanced magnetic resonance imaging techniques with vessel wall studies, specifically Black Blood (bbMRI), may offer insights into vascular wall instability and predict rupture. This case series aims to assess bbMRI as a predictive diagnostic tool for brain arteriovenous malformations (bAVMs) rupture, suggesting early treatment. MATERIAL AND METHODS A prospective study included demographic, clinical, and neuroimaging data from a consecutive series of patients with ruptured or unruptured bAVMs, regardless of age or gender, between October 2018 and March 2024. All patients underwent MRI brain resonance with Black Blood study. Those with impaired renal function were excluded. Statistical analyses tested sample homogeneity. Univariate and multivariate logistical regressions assessed bbMRI as a rupture predictor for bAVMs, with a p-value set at < 0.05. RESULTS Ninety patients were retrieved: 64 with unruptured and 26 with ruptured bAVMs. The mean age was 31.9 years, and 55 were female. Admission symptoms were headache, neurological deficits, and seizure in 49, 21, and 19 cases, respectively. bbMRI showed wall enhancement in 56 cases, with 19 in the ruptured and 37 unruptured groups. Univariate and multivariate analyses revealed a significant correlation between bbMRI wall enhancement and bAVM rupture (p:0.033; p:0.047). CONCLUSION bbMRI may be a useful and feasible diagnostic implement to determine vessel inflammation and the bAVMs prone to rupture. Additional studies are needed to confirm the positive bbMRI as a predictive factor for bAVMs rupture.
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Affiliation(s)
- José Maria de Campos Filho
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Brigham and Women's Hospital, Harvard Medical School, Massachusetts, United States of America
| | | | | | | | | | | | - Hugo Leonardo Dória-Netto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Raphael Wuo-Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
- Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil.
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Das S, Raffalli-Ebezant H, Kasher PR, Parry-Jones A, Patel HC. Can angiogenesis be reliably determined on digital subtraction angiography in cerebral arteriovenous malformations? Br J Neurosurg 2024:1-6. [PMID: 39513431 DOI: 10.1080/02688697.2024.2424850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/15/2024] [Accepted: 10/29/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND Angiogenesis and nascent blood vessel formation is thought to be important in cerebral arteriovenous malformation (cAVM) development and maintenance, of which little is known. Digital subtraction angiogram (DSA) features of angiogenesis in cAVMs are poorly described and the aim of this study was to describe the frequency of angiogenesis in patients who had a DSA showing a cAVM. We also sought to evaluate the intra- and inter-observer agreement of a diagnosis of angiogenesis and explore which angioarchitectural features were associated with angiogenesis. METHOD Patients that underwent a DSA were identified from the database of referred cAVM patients at the Manchester Centre for Clinical Neurosciences. Data were collected from 100 patients (102 cAVMs). cAVM angioarchitecture, including the presence of angiogenesis, was described after reviewing cAVM patient angiograms. The association of angioarchitectural features with angiogenesis was determined using univariate analysis. Ten cases were distributed amongst two other observers for reporting (inter-observer agreement). Twenty cases (including the previous 10) were reported twice by the first author, after a six-month interval (intra-observer agreement). RESULTS Angiogenesis was observed in 39 cAVMs (38.2%), with 12 having a complete border (11.8%). Most intra-observer agreement was strong (ranging from κ = 1 to 0.2), but inter-observer agreement was moderate (κ = 1 to -0.316). There was a significant association between angiogenesis and venous reflux (OR 2.52 [95% CI = 1.08-5.88]), venous congestion (OR 4.47 [95% CI = .671-2.52]), arterial ectasia (OR 16.6 [95% CI = 4.65-59.6]), and artery: vein ratio (4.28 [95% CI = .956-19.15]). CONCLUSION We have demonstrated perinidal angiogenesis can be visualised on angiograms with moderate reliability, and that it may be related to angioarchitectural characteristics associated with venous hypertension.
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Affiliation(s)
- Suparna Das
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Science, Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Helen Raffalli-Ebezant
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Paul R Kasher
- Division of Neuroscience and Experimental Psychology, Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Adrian Parry-Jones
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Science, Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Hiren C Patel
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Science, Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
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Brosnan C, Henry J, McHugh P, Griffin E, Mulligan M, Brett F, MacNally S, O'Hare A, Looby S. Utility of Early Postoperative DWI to Assess the Extent of Resection of Adult-Type World Health Organization Grade 2 and 3 Diffuse Gliomas. AJNR Am J Neuroradiol 2024; 45:1769-1776. [PMID: 39326884 PMCID: PMC11543062 DOI: 10.3174/ajnr.a8397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/18/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND AND PURPOSE World Health Organization (WHO) grade 2 and 3 diffuse gliomas account for approximately 5% of primary brain tumors. They are invasive and infiltrative tumors and have considerable morbidity, causing progressive neurologic deterioration. The mean survival time is <10 years from diagnosis. Surgical debulking represents first-line management. The extent of resection is associated with progression-free and overall survival. Radiologic assessment of the extent of resection is challenging. This can be underestimated on early postoperative MRI, meaning that accurate assessment may be achieved only on delayed follow-up imaging. We hypothesized that DWI may help facilitate more reliable estimates of the extent of resection on early postoperative MRI. This study aimed to assess the utility of DWI in early postoperative MRI to evaluate the extent of resection. MATERIALS AND METHODS A single-center observational cohort study was performed. All patients with histologically confirmed WHO grade 2 and 3 gliomas managed with surgical debulking between January 2015 and December 2020 were identified. Preoperative, early postoperative, and follow-up imaging were reviewed independently by 2 consultant neuroradiologists. The extent of resection was estimated with and without DWI sequences for each case. RESULTS Two hundred twenty-four patients with WHO grade 2 and 3 gliomas were managed with surgical debulking between 2015 and 2020. DWI was not performed on early postoperative MRI in 2 patients. With the use of DWI, the extent of resection was upgraded in 30% of cases (n = 66/222) and classified as "complete" or "supramaximal" in 58% of these patients (n = 38/66). In cases in which the extent of resection was upgraded with the use of DWI, signal abnormality was stable or reduced at follow-up in 78% (n = 49/63). In cases with worsening signal abnormality, 64% were deemed to be secondary to adjuvant radiation therapy (n = 9/14). Eight percent (n = 5/63) of patients with an increased estimated extent of resection using DWI demonstrated signal progression attributed to true disease progression at follow-up. CONCLUSIONS DWI is a helpful and reliable adjunct in differentiating residual tumor from marginal ischemia in early postoperative MRI in WHO grade 2 and 3 diffuse gliomas and increases the accuracy in assessing the extent of resection. It should be used routinely in these cases.
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Affiliation(s)
- Conor Brosnan
- From the Department of Radiology (C.B., A.O., S.L.), Beaumont Hospital, Dublin, Ireland
| | - Jack Henry
- Department of Neurosurgery (J.H., P.M., E.G., S.M.), Beaumont Hospital, Dublin, Ireland
| | - Paul McHugh
- Department of Neurosurgery (J.H., P.M., E.G., S.M.), Beaumont Hospital, Dublin, Ireland
| | - Emma Griffin
- Department of Neurosurgery (J.H., P.M., E.G., S.M.), Beaumont Hospital, Dublin, Ireland
| | - Martin Mulligan
- Department of Pathology (M.M., F.B.), Beaumont Hospital, Dublin, Ireland
| | - Francesca Brett
- Department of Pathology (M.M., F.B.), Beaumont Hospital, Dublin, Ireland
| | - Stephen MacNally
- Department of Neurosurgery (J.H., P.M., E.G., S.M.), Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- From the Department of Radiology (C.B., A.O., S.L.), Beaumont Hospital, Dublin, Ireland
| | - Seamus Looby
- From the Department of Radiology (C.B., A.O., S.L.), Beaumont Hospital, Dublin, Ireland
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Li Z, Zhang J, Han H, Gao D, Jin H, Ma L, Li R, Li A, Zhang H, Yuan K, Wang K, Zhu Q, Wang C, Yan D, Lu J, Zhang Y, Zhao Y, Li Y, Sun S, Zhao Y, Chen Y, Chen X. Association of the combined stereotactic radiosurgery and embolization strategy and long-term outcomes in brain arteriovenous malformations with a volume >10 ml: A nationwide multicenter observational prospective cohort study. Radiother Oncol 2024; 200:110530. [PMID: 39251110 DOI: 10.1016/j.radonc.2024.110530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 09/02/2024] [Accepted: 09/05/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND To assess the long-term outcome of large brain arteriovenous malformations (AVMs) (volume > 10 ml) underwent combined embolization and stereotactic radiosurgery (E+SRS) versus SRS alone. METHODS Patients were recruited from a nationwide multicenter prospective collaboration registry (MATCH study, August 2011-August 2021) and categorized into E+SRS and SRS alone cohorts. Propensity score-matched survival analysis was employed to control for potential confounding variables. The primary outcome was a composite event of non-fatal hemorrhagic stroke or death. Secondary outcomes were favorable patient outcomes, AVM obliteration, favorable neurological outcomes, seizure, worsened mRS score, radiation-induced changes (RIC), and embolization complications. Furthermore, the efficacy of distinct embolization strategies was evaluated. Hazard ratios (HRs) were computed utilizing Cox proportional hazard models. RESULTS Among 1063 AVMs who underwent SRS with or without prior embolization, 176 patients met the enrollment criteria. Following propensity score matching, the final analysis encompassed 98 patients (49 pairs). Median (interquartile range) follow-up duration for primary outcomes spanned 5.4 (2.7-8.4) years. Overall, the E+SRS strategy demonstrated a trend toward reduced incidence of primary outcomes compared to the SRS alone strategy (1.44 vs 2.37 per 100 patient-years; HR, 0.58 [95 % CI, 0.17-1.93]). Regardless of embolization degree or strategy, stratified analyses further consistently revealed a similar trend, albeit without achieving statistical significance. Secondary outcomes generally exhibited equivalence, but the combined approach showed potential superiority in most measures. CONCLUSIONS This study suggests a trend toward lower long-term non-fatal hemorrhagic stroke or death risks with the E+SRS strategy when compared to SRS alone in large AVMs (volume > 10 ml).
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Affiliation(s)
- Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qinghui Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengzhuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Shanxi, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Calafiore R, Burke RM, Becerril-Gaitan A, Chen CJ, Oravec CS, Belanger K, Ding D, Yang HC, Kondziolka D, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Characterization of Pediatric Infratentorial Arteriovenous Malformations: A Retrospective, Multicenter Cohort Study. Neurosurgery 2024; 95:1064-1071. [PMID: 38700839 DOI: 10.1227/neu.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/11/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Infratentorial arteriovenous malformations (AVMs) harbor different characteristics compared with supratentorial AVMs. This study aims to explore the unique characteristics of pediatric infratentorial AVMs and their response to single session stereotactic radiosurgery (SRS). METHODS The International Radiosurgery Research Foundation database of pediatric patients with AVM (age <18 years) who underwent SRS was retrospectively reviewed. Baseline demographics, AVM characteristics, outcomes, and complications post-SRS were compared between infratentorial and supratentorial pediatric AVMs. Unfavorable outcome was defined as the absence of AVM obliteration, post-SRS hemorrhage, or permanent radiation-induced changes at last follow-up. RESULTS A total of 535 pediatric AVMs managed with SRS with a median follow-up of 67 months (IQR 29.0-130.6) were included, with 69 being infratentorial and 466 supratentorial. The infratentorial group had a higher proportion of deep location (58.4% vs 30.3%, P = <.001), deep venous drainage (79.8% vs 61.8%, P = .004), and prior embolization (26.1% vs 15.7%, P = .032). There was a higher proportion of hemorrhagic presentation in the infratentorial group (79.7% vs 71.3%, P = .146). There was no statistically significant difference in the odds of an unfavorable outcome (odds ratio [OR] = 1.36 [0.82-2.28]), AVM obliteration (OR = 0.85 [0.5-1.43]), post-SRS hemorrhage (OR = 0.83 [0.31-2.18]), or radiologic radiation-induced changes (OR = 1.08 [0.63-1.84]) between both cohorts. No statistically significant difference on the rates of outcomes of interest and complications were found in the adjusted model. CONCLUSION Despite baseline differences between infratentorial and supratentorial pediatric AVMs, SRS outcomes, including AVM obliteration and post-SRS hemorrhage rates, were comparable amongst both groups. SRS appears to have a similar risk profile and therapeutic benefit to infratentorial pediatric AVMs as it does for those with a supratentorial location.
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Affiliation(s)
- Rebecca Calafiore
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Rebecca M Burke
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Katherine Belanger
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville , Kentucky , USA
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York , New York , USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke , Quebec , Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke , Quebec , Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak , Michigan , USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan , Puerto Rico , USA
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland , Ohio , USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miami , Florida , USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
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Winkler EA, Scherschinski L, Catapano JS, DiDomenico JD, Hanalioglu S, Lawton MT. Posterior Interhemispheric-Transtentorial Approach for Resection of an Arteriovenous Malformation of the Superior Medullary Velum and Fourth Ventricle: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 27:660-661. [PMID: 38683955 DOI: 10.1227/ons.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/05/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Vysakha KV, Jose M, Pande A, Salini RA, Pavithran V, Arjun S, Thomas B, Thomas SV. Risk of Bleed During Pregnancy in Women with Epilepsy Due to Cerebral Vascular Malformations. Neurol India 2024; 72:1218-1222. [PMID: 39690995 DOI: 10.4103/neuroindia.ni_1455_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/21/2021] [Indexed: 12/19/2024]
Abstract
BACKGROUND Cerebral vascular malformations are rare but important causes of epilepsy in young women. The risk of bleed during pregnancy and delivery as well as the fetal outcomes are important concerns for women with epilepsy (WWE) due to cerebral vascular malformations (EVM). OBJECTIVES We compared the maternal and fetal outcomes of a cohort of EVM with women with focal epilepsy due to other causes (ENVM). METHODS AND MATERIAL We identified all EVMs in the Kerala Registry of Epilepsy and Pregnancy and compared their characteristics with that of a set of randomly selected ENVM in the same registry. The clinical characteristics, pregnancy outcome, and seizure risk during pregnancy from the vascular malformations were compared between the two groups with Chi-square test and multivariate logistic regression after adjustment for age, epilepsy classification, and AED usage. RESULTS There were 45 women with EVM (arteriovenous malformations: 25, cavernoma: 20) in this registry between 1998 and 2018. The EVM and ENVM groups (n = 96) had similar rates of seizure relapse during pregnancy (37.1% vs. 55.1%), fetal loss (11.4% vs. 13.5%), and fetal malformations (9.4% vs. 9%). The rate of delivery by cesarean section, adjusted for maternal age, was higher for the EVM group (61.2% vs. 39%, odds ratio = 2.79, 95% CI: 0.99-7.9, P = 0.05). AVM bled during pregnancy for three women (none of the cavernoma had bled during pregnancy). CONCLUSIONS Maternal and fetal outcomes were comparable for the EVM and ENVM groups, but the former had a higher rate of cesarean section. AVM bled during pregnancy for 15% of women.
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Affiliation(s)
- Kavadisseril V Vysakha
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Manna Jose
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Aniket Pande
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Reshma A Salini
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Veena Pavithran
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - S Arjun
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Bejoy Thomas
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sanjeev Varghese Thomas
- Kerala Registry of Epilepsy and Pregnancy Study Group, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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