Skip to main content

Advertisement

SpringerLink
Log in

Impact of flow and angioarchitecture on brain arteriovenous malformation outcome after gamma knife radiosurgery: the role of hemodynamics and morphology in obliteration

  • Original Article - Vascular Neurosurgery - Arteriovenous malformation
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Few studies have evaluated the relationship between brain arteriovenous malformations (bAVMs) angioarchitecture and the response to Gamma Knife Stereotactic Radiosurgery (GKSR).

Methods

A prospectively enrolled single-center cohort of patients with bAVMs treated by GKSR has been studied to define independent predictors of obliteration with particular attention to angioarchitectural variables. Only patients older than 18 years old (y.o.), who underwent baseline digital subtraction angiography (DSA) and clinico-radiological follow-up of at least 36 months, were included in the study.

Results

Data of 191 patients were evaluated. After a mean follow-up of 80 months (range 37–173), total obliteration rate after first GKSR treatment was 66%. Mean dose higher than 22 Gy (P = .019, OR = 2.39, 95% CI 1.15–4.97) and flow rate dichotomized into high vs non-high (P < .001, OR = 0.23, 95% CI 0.11–0.51) resulted to be independent predictors of obliteration. Flow-surrogate angioarchitectural features did not emerge as independent outcome predictors.

Conclusions

Flow rate seems to be associated in predicting outcome after GKSR conferring high-flow AVM a lower occlusion rate. Its role should be considered when planning radiosurgical treatment of bAVM, and it could be added to other parameters used in GKRS outcome predicting scales.

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

Similar content being viewed by others

Abbreviations

bAVMs:

Brain arteriovenous malformations

GKSR:

Gamma Knife Stereotactic Radiosurgery

DSA:

Digital subtraction angiography

OR:

Odds ratio

CI:

Confidence interval

MRI:

Magnetic resonance imaging

SRS:

Stereotactic radiosurgery

AED :

Antiepileptic drug

ROC:

Receiver operating characteristic

AUC:

Area under ROC curve

References

  1. Abla AA, Rutledge WC, Seymour ZA et al (2015) A treatment paradigm for high-grade brain arteriovenous malformations: volume-staged radiosurgical downgrading followed by microsurgical resection. J Neurosurg 122(2):419–432

    Article  Google Scholar 

  2. Alexander MD, Cooke DL, Nelson J, Guo DE, Dowd CF, Higashida RT, Halbach VV, Lawton MT, Kim H, Hetts SW (2015) Association between venous angioarchitectural features of sporadic brain arteriovenous malformations and intracranial hemorrhage. AJNR Am J Neuroradiol 36(5):949–952

    Article  CAS  Google Scholar 

  3. Bose R, Agrawal D, Singh M, Kale SS, Gopishankar N, Bisht RK, Sharma BS (2015) Draining vein shielding in intracranial arteriovenous malformations during gamma-knife: a new way of preventing post gamma-knife edema and hemorrhage. Neurosurgery 76(5):623–632

    Article  Google Scholar 

  4. Chang JH, Chang JW, Park YG, Chung SS (2000) Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 93(Suppl 3):96–101

    Article  Google Scholar 

  5. Cuong NN, Luu VD, Tuan TA, Linh LT, Hung KD, Ngoc VTN, Sharma K, Pham VH, Chu DT (2018) Conventional digital subtractional vs non-invasive MR angiography in the assessment of brain arteriovenous malformation. Clin Neurol Neurosurg. https://doi.org/10.1016/j.clineuro.2018.03.022

  6. Da Costa L, Wallace MC, Ter Brugge KT, O’ Kelly C, Willinsky RA, Tymianski M (2009) The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 40(1):100–105

    Article  Google Scholar 

  7. Ding D, Yen CP, Starke RM, Xu Z, Sun X, Sheehan JP (2014) Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations. Br J Neurosurg 28(5):666–674

    Article  Google Scholar 

  8. Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC (2017) Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 48(8):e200–e224

    Article  Google Scholar 

  9. Franzin A, Panni P, Spatola G, Vecchio AD, Gallotti AL, Gigliotti CR, Cavalli A, Donofrio CA, Mortini P (2016) Results of volume-staged fractionated gamma knife radiosurgery for large complex arteriovenous malformations: obliteration rates and clinical outcomes of an evolving treatment paradigm. J Neurosurg 125(Suppl 1):104–113

    Article  Google Scholar 

  10. Fukuoka S, Takanashi M, Seo Y, Suematsu K, Nakamura JI (1998) Radiosurgery for arteriovenous malformations with gamma-knife: a multivariate analysis of factors influencing the complete obliteration rate. J Clin Neurosci 5(SUPPL.1):68–71

    Article  Google Scholar 

  11. Haw CS, terBrugge K, Willinsky R, Tomlinson G (2006) Complications of embolization of arteriovenous malformations of the brain. J Neurosurg 104(2):226–232

    Article  Google Scholar 

  12. Kano H, Kondziolka D, Flickinger JC, Park K-J, Parry PV, Yang H, Sirin S, Niranjan A, Novotny J, Lunsford LD (2012) Stereotactic radiosurgery for arteriovenous malformations, part 6: multistaged volumetric management of large arteriovenous malformations. J Neurosurg 116(1):54–65

    Article  Google Scholar 

  13. Kim H, Salman RA-S, McCulloch CE, Stapf C, Young WL, Coinvestigators M (2014) Untreated brain arteriovenous malformation. Neurology 83(7):590–597

    Article  Google Scholar 

  14. Kwon Y, Jeon SR, Kim JH, Lee JK, Ra DS, Lee DJ, Kwun BD (2000) Analysis of the causes of treatment failure in gamma knife radiosurgery for intracranial arteriovenous malformations. J Neurosurg 93(Suppl 3):104–106

    Article  Google Scholar 

  15. Lang S, Gölitz P, Struffert T, Rösch J, Rössler K, Kowarschik M, Strother C, Doerfler A (2017 Jun) 4D DSA for dynamic visualization of cerebral vasculature: a single-center experience in 26 cases. AJNR Am J Neuroradiol 38(6):1169–1176. https://doi.org/10.3174/ajnr.A5161

    Article  CAS  PubMed  Google Scholar 

  16. MacDonald ME, Dolati P, Mitha AP, Wong JH, Frayne R (2016) Flow and pressure measurements in aneurysms and arteriovenous malformations with phase contrast MR imaging. Magn Reson Imaging. https://doi.org/10.1016/j.mri.2016.07.007

  17. Meder JF, Oppenheim C, Blustajn J, Nataf F, Merienne L, Lefkoupolos D, Laurent A, Merland JJ, Schlienger M, Fredy D (1997) Cerebral arteriovenous malformations: the value of radiologic parameters in predicting response to radiosurgery. Am J Neuroradiol 18(8):1473–1483

  18. Monaco RG, Alvarez H, Goulao A, Pruvost P, Lasjaunias P (1990) Posterior fossa arteriovenous malformations—angioarchitecture in relation to their hemorrhagic episodes. Neuroradiology 31(6):471–475

    Article  Google Scholar 

  19. Nakstad PH, Nornes H (1994) Superselective angiography, embolisation and surgery in treatment of arteriovenous malformations of the brain. Neuroradiology 36(5):410–413

    Article  CAS  Google Scholar 

  20. Ognard J, Magro E, Caroff J, Ben Salem D, Andouard S, Nonent M, Gentric JC (2018 May) A new time-resolved 3D angiographic technique (4D DSA): description, and assessment of its reliability in Spetzler-Martin grading of cerebral arteriovenous malformations. Neuroradiol. 45(3):177–185. https://doi.org/10.1016/j.neurad.2017.11.004

    Article  Google Scholar 

  21. Paúl L, Casasco A, Kusak ME, Martínez N, Rey G, Martínez R (2014) Results for a series of 697 arteriovenous malformations treated by gamma knife. Neurosurgery 75(5):568–583

    Article  Google Scholar 

  22. Pollock BE, Flickinger JC, Lunsford LD, Maitz A, Kondziolka D (1998) Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42(6):1239–1247

    Article  CAS  Google Scholar 

  23. Pollock BE, Kline RW, Stafford SL, Foote RL, Schomberg PJ (2000) The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 48(3):817–824

    Article  CAS  Google Scholar 

  24. Schuster L, Schenk E, Giesel F, Hauser T, Gerigk L, Zabel-Du-Bois A, Essig M (2011) Changes in AVM angio-architecture and hemodynamics after stereotactic radiosurgery assessed by dynamic MRA and phase contrast flow assessments: a prospective follow-up study. Eur Radiol. https://doi.org/10.1007/s00330-010-2031-0

  25. Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65(4):476–483

    Article  CAS  Google Scholar 

  26. Starke RM, Yen C-P, Ding D, Sheehan JP (2013) A practical grading scale for predicting outcome after radiosurgery for arteriovenous malformations: analysis of 1012 treated patients. J Neurosurg 119(4):981–987

    Article  Google Scholar 

  27. Statham P, Macpherson P, Johnston R, Forster DM, Hume Adams J, Todd NV (1990) Cerebral radiation necrosis complicating stereotactic radiosurgery for arteriovenous malformation. J Neurol Neurosurg Psychiatry 53(6):476–479

    Article  CAS  Google Scholar 

  28. Taeshineetanakul P, Krings T, Geibprasert S, Menezes R, Agid R, Terbrugge KG, Schwartz ML (2012) Angioarchitecture determines obliteration rate after radiosurgery in brain arteriovenous malformations. Neurosurgery 71(6):1071–1078

    Article  Google Scholar 

  29. Taylor CL, Dutton K, Rappard G, Pride GL, Replogle R, Purdy PD, White J, Giller C, Kopitnik TA, Samson DS (2004) Complications of preoperative embolization of cerebral arteriovenous malformations. J Neurosurg 100(5):810–812

    Article  Google Scholar 

  30. Valavanis A, Yaşargil MG (1998) The endovascular treatment of brain arteriovenous malformations. Adv Tech Stand Neurosurg 24:131–214

    Article  CAS  Google Scholar 

  31. Yen CP, Schlesinger D, Sheehan JP (2012) Natural history of cerebral arteriovenous malformations and the risk of hemorrhage after radiosurgery. Prog Neurol Surg. 27:5-21. https://doi.org/10.1159/000341616.

  32. Yen CP, Sheehan JP, Schwyzer L, Schlesinger D (2011) Hemorrhage risk of cerebral arteriovenous malformations before and during the latency period after gamma knife radiosurgery. Stroke 42(6):1691–1696

    Article  Google Scholar 

  33. Yuki I, Kim RH, Duckwiler G, Jahan R, Tateshima S, Gonzalez N, Gorgulho A, Diaz JL, De Salles AA, Viñuela F (2010) Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular embolization in multimodality treatment: clinical article. J Neurosurg. https://doi.org/10.3171/2009.9.JNS081588

  34. Zipfel GJ, Bradshaw P, Bova FJ, Friedman WA (2004) Do the morphological characteristics of arteriovenous malformations affect the results of radiosurgery? J Neurosurg 101(3):393–401

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy

    Pietro Panni, Alberto Luigi Gallotti, Ahmed Badry Shehata, Luigi Albano, Camillo Ferrari da Passano, Raffaella Lina Alessandra Barzaghi, Jody Filippo Capitanio & Pietro Mortini

  2. Department of Neuroradiology, Interventional Neuroradiology Unit, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy

    Pietro Panni, Ahmed Badry Shehata, Claudio Righi, Franco Simionato, Francesco Scomazzoni & Andrea Falini

  3. Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Milan, Italy

    Carmen Rosaria Gigliotti, Ahmed Badry Shehata & Antonella del Vecchio

  4. Department of Neurosurgery, Suez Canal University, Ismailia, Egypt

    Ahmed Badry Shehata

Authors
  1. Pietro Panni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alberto Luigi Gallotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Carmen Rosaria Gigliotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ahmed Badry Shehata
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Luigi Albano
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Camillo Ferrari da Passano
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Raffaella Lina Alessandra Barzaghi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jody Filippo Capitanio
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Claudio Righi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Franco Simionato
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Francesco Scomazzoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Antonella del Vecchio
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Andrea Falini
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Pietro Mortini
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Pietro Panni.

Ethics declarations

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Vascular Neurosurgery - Arteriovenous malformation

Electronic supplementary material

ESM 1

(DOCX 24 kb).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Panni, P., Gallotti, A.L., Gigliotti, C.R. et al. Impact of flow and angioarchitecture on brain arteriovenous malformation outcome after gamma knife radiosurgery: the role of hemodynamics and morphology in obliteration. Acta Neurochir 162, 1749–1757 (2020). https://doi.org/10.1007/s00701-020-04351-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-020-04351-4

Keywords

Search

Navigation