Skip to main content

Advertisement

SpringerLink
Log in

Stereotactic radiosurgery planning based on time-resolved CTA for arteriovenous malformation: a case report and review of the literature

  • Case Report - Vascular
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Stereotactic radiosurgery has long been recognized as the optimal form of management for high-grade arteriovenous malformations not amenable to surgical resection. Radiosurgical plans have generally relied upon the integration of stereotactic magnetic resonance angiography (MRA), standard contrast-enhanced magnetic resonance imaging (MRI), or computed tomography angiography (CTA) with biplane digital subtraction angiography (DSA). Current options are disadvantageous in that catheter-based biplane DSA is an invasive test associated with a small risk of complications and perhaps more importantly, the two-dimensional nature of DSA is an inherent limitation in creating radiosurgical contours. The necessity of multiple scans to create DSA contours for radiosurgical planning puts patients at increased risk. Furthermore, the inability to import two-dimensional plans into some radiosurgery programs, such as Cyberknife TPS, limits treatment options for patients. Defining the nidus itself is sometimes difficult in any of the traditional modalities as all draining veins and feeding arteries are included in the images. This sometimes necessitates targeting a larger volume, than strictly necessary, with stereotactic radiosurgery for treatment of the AVM. In this case report, we show the ability to use a less-invasive and three-dimensional form of angiography based on time-lapsed CTA (4D-CTA) rather than traditional DSA for radiosurgical planning. 4D-CTA may allow generation of a series of images, which can show the flow of contrast through the AVM. A review of these series may allow the surgeon to pick and use a volume set that best outlines the nidus with least interference from feeding arteries or draining veins. In addition, 4D-CTA scans can be uploaded into radiosurgery programs and allow three-dimensional targeting. This is the first reported case demonstrating the use of a 4D CTA and an MRI to delineate the AVM nidus for Gamma Knife radiosurgery, with complete obliteration of the nidus over time and subsequent management of associated radiation necrosis with bevacizumab.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Bednarz G, Downes B, Werner-Wasik M, Rosenwasser RH (2000) Combining stereotactic angiography and 3D time-of-flight magnetic resonance angiography in treatment planning for arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 46:1149–1154

    Article  CAS  PubMed  Google Scholar 

  2. Buis DR, Lagerwaard FJ, Barkhof F, Dirven CM, Lycklama GJ, Meijer OW, van den Berg R, Langendijk HA, Slotman BJ, Vandertop WP (2005) Stereotactic radiosurgery for brain AVMs: role of interobserver variation in target definition on digital subtraction angiography. Int J Radiat Oncol Biol Phys 62:246–252

    Article  PubMed  Google Scholar 

  3. Chandran A, Radon M, Biswas S, Das K, Puthuran M, Nasher H (2015) Novel use of 4D-CTA in imaging of intranidal aneurysms in an acutely ruptured arteriovenous malformation: is this the way forward? BMJ Case Rep. doi:10.1136/bcr-2015-011784

    Google Scholar 

  4. D'Orazio F, Splendiani A, Gallucci M (2014) 320-row detector dynamic 4D-CTA for the assessment of brain and spinal cord vascular shunting malformations. A technical note. Neuroradiol J 27:710–717

    Article  PubMed  PubMed Central  Google Scholar 

  5. Essig M, Engenhart R, Knopp MV, Bock M, Scharf J, Debus J, Wenz F, Hawighorst H, Schad LR, van Kaick G (1996) Cerebral arteriovenous malformations: improved nidus demarcation by means of dynamic tagging MR-angiography. Magn Reson Imaging 14:227–233

    Article  CAS  PubMed  Google Scholar 

  6. Furuse M, Nonoguchi N, Kawabata S, Miyata T, Toho T, Kuroiwa T, Miyatake S (2015) Intratumoral and peritumoral post-irradiation changes, but not viable tumor tissue, may respond to bevacizumab in previously irradiated meningiomas. Radiat Oncol 10:156

    Article  PubMed  PubMed Central  Google Scholar 

  7. Gonzalez J, Kumar AJ, Conrad CA, Levin VA (2007) Effect of bevacizumab on radiation necrosis of the brain. Int J Radiat Oncol Biol Phys 67:323–326

    Article  CAS  PubMed  Google Scholar 

  8. Haridass A, Maclean J, Chakraborty S, Sinclair J, Szanto J, Iancu D, Malone S (2015) Dynamic CT angiography for cyberknife radiosurgery planning of intracranial arteriovenous malformations: a technical/feasibility report. Radiol Oncol 49:192–199

    Article  PubMed  PubMed Central  Google Scholar 

  9. Hoogenboom TC, van Beurden RM, van Teylingen B, Schenk B, Willems PW (2012) Optimization of the reconstruction interval in neurovascular 4D-CTA imaging. A technical note. Interv Neuroradiol 18:377–379

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Kortman HG, Smit EJ, Oei MT, Manniesing R, Prokop M, Meijer FJ (2015) 4D-CTA in neurovascular disease: A review. AJNR Am J Neuroradiol 36:1026–1033

    Article  CAS  PubMed  Google Scholar 

  11. Levin VA, Bidaut L, Hou P, Kumar AJ, Wefel JS, Bekele BN, Grewal J, Prabhu S, Loghin M, Gilbert MR, Jackson EF (2011) Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the central nervous system. Int J Radiat Oncol Biol Phys 79:1487–1495

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Miyatake S, Nonoguchi N, Furuse M, Yoritsune E, Miyata T, Kawabata S, Kuroiwa T (2015) Pathophysiology, diagnosis, and treatment of radiation necrosis in the brain. Neurol Med Chir 55:50–59

    Article  Google Scholar 

  13. Ono Y, Abe K, Suzuki K, Iimura H, Sakai S, Uchiyama S, Okada Y (2013) Usefulness of 4D-CTA in the detection of cerebral dural sinus occlusion or stenosis with collateral pathways. Neuroradiol J 26:428–438

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Sneed PK, Mendez J, Vemer-van den Hoek JG, Seymour ZA, Ma L, Molinaro AM, Fogh SE, Nakamura JL, McDermott MW (2015) Adverse radiation effect after stereotactic radiosurgery for brain metastases: incidence, time course, and risk factors. J Neurosurg 123:373–386

    Article  CAS  PubMed  Google Scholar 

  15. Willems PW, Taeshineetanakul P, Schenk B, Brouwer PA, Terbrugge KG, Krings T (2012) The use of 4D-CTA in the diagnostic work-up of brain arteriovenous malformations. Neuroradiology 54:123–131

    Article  PubMed  Google Scholar 

  16. Williams BJ, Park DM, Sheehan JP (2012) Bevacizumab used for the treatment of severe, refractory perilesional edema due to an arteriovenous malformation treated with stereotactic radiosurgery. J Neurosurg 116:972–977

    Article  CAS  PubMed  Google Scholar 

  17. Xiang-Pan L, Yuxin C, Xiao-Fei W, Na L, Tang-Peng X, Xiao-Tao X, Chang-Li R, Wei-Guo H, Qi-Bin S (2015) Bevacizumab alleviates radiation-induced brain necrosis: a report of four cases. J Cancer Res Ther 11:485–487

    Article  PubMed  Google Scholar 

  18. Yano H, Nakayama N, Morimitsu K, Futamura M, Ohe N, Miwa K, Shinoda J, Iwama T (2014) Changes in protein level in the cerebrospinal fluid of a patient with cerebral radiation necrosis treated with bevacizumab. Clin Med Insights Oncol 8:153–157

    Article  PubMed  PubMed Central  Google Scholar 

  19. Ye X, Wang H, Huang Y, Zhou S, Gao X (2014) Surgical treatment for ruptured dural arteriovenous fistula with large intracranial hematoma. Int J Clin Exp Med 7:5244–5251

    PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

Brandon Lucke-Wold received funding from the Neurosurgery Research and Education Foundation Medical Student Summer Fellowship, American Foundation of Pharmaceutical Education Predoctoral Fellowship, and American Medical Association Foundation Seed Grant.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, West Virginia University School of Medicine, One Medical Center Drive, Suite 9183, Morgantown, WV, 26506, USA

    Ryan C. Turner, Brandon P. Lucke-Wold, Darnell Josiah & Sanjay Bhatia

  2. Center for Neuroscience, West Virginia University School of Medicine, Morgantown, WV, 26506, USA

    Ryan C. Turner, Brandon P. Lucke-Wold, Darnell Josiah & Sanjay Bhatia

  3. Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA

    Javier Gonzalez

  4. Department of Radiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA

    Matthew Schmidt & Abdul Rahman Tarabishy

Authors
  1. Ryan C. Turner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brandon P. Lucke-Wold
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Darnell Josiah
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Javier Gonzalez
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Matthew Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Abdul Rahman Tarabishy
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sanjay Bhatia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sanjay Bhatia.

Ethics declarations

Conflict of interest

The author(s) declare that they have no competing interests.

Informed patient consent

The patient has consented to submission of this case report to the journal.

Additional information

Comment:

Time-resolved computed tomographic angiography (CTA) is also known as dynamic CTA, multi-phase CTA, or 4D-CTA. As opposed to conventional CTA, 4D-CTA allows for a spatial and temporal resolution of vascular lesions. 4D-CTA has mostly been a diagnostic tool for neuroradiology. Images have been derived from conventional CT scans and C-arm reconstruction in settings such as the replacement of digital subtraction angiography (DSA) or a supplement to DSA in the diagnosis of occlusive vascular conditions or in the diagnosis of cerebral arteriovenous malformations (AVM) (2, 3, 4, 6, 7). The present work by RC Turner et al. (5) is the first published attempt to successfully incorporate 4D-CTA into the therapeutic setting of radiosurgery. Results of radiosurgery for AVMs depend largely on the correct determination of the AVM's nidus. Anything leading to a better definition of the target volume is likely to improve the outcome of radiosurgery for AVMs. As the authors point out, the addition of two-dimensional DSA images to three-dimensional CT- and MRI volumes remains problematic in terms of accuracy. Retrospective analyses of failed occlusion of AVMs following radiosurgery often found missed or undertreated parts of the nidus due to suboptimal target definition as a likely explanation for treatment failure. 4D-CTA seems to help localize an AVM's nidus more accurately than added information derived from a two-dimensional DSA. Therefore, 4D-DSA may help increasing the likelihood of successful radiosurgery for AVM.

The present publication may serve as a proof of concept. The best technique for 4D-CTA in this particular setting may still have to be determined (1). The patient's complicated clinical course following radiosurgery has nothing to do with the implementation of 4D-CTA into the therapeutic setting but with problems inherent to radiosurgery such as dose, target volume etc. It may be a good idea to develop treatment protocols for AVMs integrating information of 4D-CTA.

Thomas Mindermann

Zurich, Switzerland

References:

1) Hoogenboom TCH, van Beurden RMJ, van Teylingen B, Schenk B, Willems PWA (2012) Optimization of the reconstruction interval in neurovascular 4D-CTA imaging. Intervent Neuroradiol 18:377–79

2) Ng FC, Datta M, Choi PM (2016) Time-resolved-4-dimensional computed-tomography angiography can correctly identify carotid pseudo-occlusion. J Stroke Cerebrovasc Dis 25:1005–6

3) Ono Y, Abe K, Suzuki K, Iimura H, Sakai S, Uchiyama S, Okada Y (2013) Usefulness of 4D-CTA in the detection of cerebral dural sinus occlusion or stenosis with collateral pathways. Neuroadiol J 26:428–38

4) Qazi E, Al-Ajlan FS, Najm M, Menon BK (2016) The role of vascular imaging in the initial assessment of patients with acute ischemic stroke. Curr Neurol Neurosci Rep 16:32

5) Turner RC, Lucke-Wold BP, Josiah D, Gonzalez J, Schmidt M, Tarabishy AR, Bhatia S (2016) Stereotactic radiosurgery planning based on time-resolved CTA for arteriovenous malformation: a case report and review of the literature. Acta Neurochir

6) Willems PWA, Taeshineetanakul P, Schenk B, Brouwer PA, Terbrugge KG, Krings T (2012) The use of 4D-CTA in the diagnostic work-up of brain arteriovenous malformations. Neuroradiol 54:123–31

7) Yang P, Niu K, Wu Y, Struffert T, Dorfler A, Schafer S, Royalty K, Strother C, Chen GH (2015) Time-resolved C-arm computed tomographic angiography derived from computed perfusion acquisition: new capability for one-stop-shop acute ischemic stroke treatment in the angiosuite. Stroke 46:3383–9

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Turner, R.C., Lucke-Wold, B.P., Josiah, D. et al. Stereotactic radiosurgery planning based on time-resolved CTA for arteriovenous malformation: a case report and review of the literature. Acta Neurochir 158, 1555–1562 (2016). https://doi.org/10.1007/s00701-016-2874-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-016-2874-5

Keywords

Search

Navigation