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Response to Editorials

Arteriovenous malformations and radiosurgery

Douglas Kondziolka, Hideyuki Kano, and L. Dade Lunsford

critical but relatively rare vascular disorder presents a wide spectrum of features that influence decision making, management options, and outcomes: volume, anatomical location, symptoms, signs, blood flow, occurrence of prior bleeding events, presence of associated aneurysms, venous outflow, and age at presentation. The overriding risk for patients is the risk of often tragic brain hemorrhage and death. Previous publications on the natural history of untreated AVMs as well as management publications that define outcomes at AVM centers of excellence have improved our

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Mohamed Samy Elhammady and Roberto C. Heros

treatment option should be based on several factors such as the extent of eloquent cortex involvement (see below), presence of high-risk angiographic features (associated aneurysm, venoocclusive disease, and so on), patient age and overall heath, as well as the treating neurosurgeon's personal experience. Although resection of such lesions in expert hands has been reported with acceptable morbidity, we believe, as this article shows, that SRS is a relatively effective and, in our opinion, possibly safer alternative. 2 , 5 , 7 Grade IIIb AVMs (3–6 cm, in noneloquent

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Douglas Kondziolka, L. Dade Lunsford, and John R. W. Kestle

patients who had angiograms (73 cases), no vascular abnormality was identified in the area of the lesion. All patients with prior symptomatic hemorrhage had confirmation of gross bleeding on imaging studies. Two patients had coexisting venous angiomas ( Fig. 1 ). No patient who underwent angiography had an associated AVM or aneurysm. Fig. 1. Magnetic resonance images in a 38-year-old man with a cavernous malformation medial to a venous malformation within the left middle cerebellar peduncle. a: Long-TR image showing the mixed-signal cavernous malformation and a

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Jason P. Sheehan, Douglas Kondziolka, John Flickinger, and L. Dade Lunsford

Instruments, Atlanta, GA). The GKS methodology used to treat pituitary lesions is described in detail elsewhere. 36 An MR image of the sellar region was obtained for each patient by using a 1.5-tesla imager. One-millimeter-thick axial slices with volume acquisition, fat suppression, and intravenous gadolinium contrast were obtained. In all cases prior to 1989 or when a patient could not undergo MR imaging (for example, because of a non—MR imaging compatible aneurysm clip or a pacemaker), high-resolution 1-mm-thick axial CT scans with intravenous contrast were obtained

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Satoshi Maesawa, John C. Flickinger, Douglas Kondziolka, and L. Dade Lunsford

with at least 2 years of follow-up imaging were deemed eligible for inclusion in this study. Of the 41 patients studied, 27 (66%) were women and 14 (34%) were men. The median patient age at the initial radiosurgery was 31 years (range 2–64 years). Brain locations of the lesions are shown in Table 1 . Six patients (15%) had undergone incomplete AVM resection previously. One patient had undergone surgery to clip the feeding artery after experiencing hemorrhage, and another patient had undergone aneurysm clipping. Fifteen patients (37%) had undergone one or more

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Jason Sheehan and Chun Po Yen

more dangerous to use. Also, they are radiopaque, making subsequent radiosurgical targeting more difficult. Silk and PVA particles are safer to use and are radiolucent, but vessels closed by these materials may recanalize over time. Potential benefits of embolization before SRS include decreasing the volume of the AVM nidus, reducing the risk of hemorrhage by targeting the feeding artery or perinidal/intranidal aneurysm, and reducing symptoms of steal and venous hypertension. Based on the current study and our institutional experience at the University of Virginia

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Daniel Tonetti, Hideyuki Kano, Gregory Bowden, John C. Flickinger, and L. Dade Lunsford

multiple arterial feeders and draining veins, deep venous drainage, and a varix but no prenidal or intranidal aneurysms. The SRS was performed in 2 stages separated by a 3-month interval. The minimal margin dose to the entire AVM was 16 Gy. One month after undergoing SRS, the patient became pregnant. At Week 5 of gestation, she experienced a severe headache and new dense right hemiparesis caused by AVM rupture. While under observation, the patient sustained a second hemorrhage at Week 10 of gestation, resulting in coma. Placement of an external ventricular drain was

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concerning their natural history. For example, angioarchitectural features such as prenidal and intranidal aneurysms, venous restriction, or deep venous drainage, are now well-known risk factors for hemorrhage. 7, 8, 13, 15 Before surgery, volume reduction is as important as flow reduction in helping to remove large AVMs. 14 The role of embolization also includes the occlusion of deep perforating vessels or arteries that will be hidden during surgical approach, in performing amytal testing in potential eloquent territories, and in detecting arteries en passage. Before

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hemorrhage, the risk merely regresses toward that of an unruptured lesion, just as it does for an untreated, previously ruptured aneurysm or arteriovenous malformation. Unfortunately, this paper does little to help patients and physicians make well-informed treatment decisions regarding cavernous malformations. Rather, it obscures the fact that the hemorrhage rate after radiosurgery for a cavernous malformation is greater than that anticipated from the natural history of an untreated lesion. Neurosurgical Forum: Letters to the Editor Response

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Nitin Agarwal, Michael D. White, Jonathan Cohen, L. Dade Lunsford, and D. Kojo Hamilton

2017 and rose at a rate of 4.85 operations per year (r 2 = 0.93) per graduating class. The greatest increase seen within the endovascular category was in endovascular treatment of aneurysms, which rose 1.58 cases per year (r 2 = 0.78). In contrast, open vascular procedures demonstrated a decline during the study period and decreased by 2.85 procedures per year (r 2 = 0.53). Functional, open vascular, transsphenoidal and sellar/parasellar tumor, endovascular, radiosurgery, and extracranial vascular procedures comprised 12.32%, 10.92%, 5.97%, 4.31%, 3.18%, and 2