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