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Shayan Moosa, Ching-Jen Chen, Dale Ding, Cheng-Chia Lee, Srinivas Chivukula, Robert M. Starke, Chun-Po Yen, Zhiyuan Xu and Jason P. Sheehan

Object

The aim in this paper was to compare the outcomes of dose-staged and volume-staged stereotactic radio-surgery (SRS) in the treatment of large (> 10 cm3) arteriovenous malformations (AVMs).

Methods

A systematic literature review was performed using PubMed. Studies written in the English language with at least 5 patients harboring large (> 10 cm3) AVMs treated with dose- or volume-staged SRS that reported post-treatment outcomes data were selected for review. Demographic information, radiosurgical treatment parameters, and post-SRS outcomes and complications were analyzed for each of these studies.

Results

The mean complete obliteration rates for the dose- and volume-staged groups were 22.8% and 47.5%, respectively. Complete obliteration was demonstrated in 30 of 161 (18.6%) and 59 of 120 (49.2%) patients in the dose- and volume-staged groups, respectively. The mean rates of symptomatic radiation-induced changes were 13.5% and 13.6% in dose- and volume-staged groups, respectively. The mean rates of cumulative post-SRS latency period hemorrhage were 12.3% and 17.8% in the dose- and volume-staged groups, respectively. The mean rates of post-SRS mortality were 3.2% and 4.6% in dose- and volume-staged groups, respectively.

Conclusions

Volume-staged SRS affords higher obliteration rates and similar complication rates compared with dose-staged SRS. Thus, volume-staged SRS may be a superior approach for large AVMs that are not amenable to single-session SRS. Staged radiosurgery should be considered as an efficacious component of multimodality AVM management.

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Nohra Chalouhi, Alex Whiting, Eliza C. Anderson, Samantha Witte, Mario Zanaty, Stavropoula Tjoumakaris, L. Fernando Gonzalez, David Hasan, Robert M. Starke, Shannon Hann, George M. Ghobrial, Robert Rosenwasser and Pascal Jabbour

Object

It is common practice to use a new contralateral bur hole for ventriculoperitoneal shunt (VPS) placement in subarachnoid hemorrhage (SAH) patients with an existing ventriculostomy. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, the authors have primarily used the ventriculostomy site for the VPS. The purpose of this study was to compare the safety of the 2 techniques in patients with SAH.

Methods

The rates of VPS-related hemorrhage, infection, and proximal revision were compared between the 2 techniques in 523 patients undergoing VPS placement (same site in 464 and contralateral site in 59 patients).

Results

The rate of new VPS-related hemorrhage was significantly higher in the contralateral-site group (1.7%) than in the same-site group (0%; p = 0.006). The rate of VPS infection did not differ between the 2 groups (6.4% for same site vs 5.1% for contralateral site; p = 0.7). In multivariate analysis, higher Hunt and Hess grades (p = 0.05) and open versus endovascular treatment (p = 0.04) predicted shunt infection, but the VPS technique was not a predictive factor (p = 0.9). The rate of proximal shunt revision was 6% in the same-site group versus 8.5% in the contralateralsite group (p = 0.4). In multivariate analysis, open surgery was the only factor predicting proximal VPS revision (p = 0.05).

Conclusions

The results of this study suggest that the use of the ventriculostomy site for VPS placement may be feasible and safe and may not add morbidity (infection or need for revision) compared with the use of a fresh contralateral site. This rapid and simple technique also was associated with a lower risk of shunt-related hemorrhage. While both techniques appear to be feasible and safe, a definitive answer to the question of which technique is superior awaits a higher level of medical evidence.

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Mohamed Samy Elhammady and Roberto C. Heros

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Chun-Po Yen, Dale Ding, Ching-Hsiao Cheng, Robert M. Starke, Mark Shaffrey and Jason Sheehan

Object

A relatively benign natural course of unruptured cerebral arteriovenous malformations (AVMs) has recently been recognized, and the decision to treat incidentally found AVMs has been questioned. This study aims to evaluate the long-term imaging and clinical outcomes of patients with asymptomatic, incidentally discovered AVMs treated with Gamma Knife surgery (GKS).

Methods

Thirty-one patients, each with an incidentally diagnosed AVM, underwent GKS between 1989 and 2009. The nidus volumes ranged from 0.3 to 11.1 cm3 (median 3.2 cm3). A margin dose between 15 and 26 Gy (median 20 Gy) was used to treat the AVMs. Four patients underwent repeat GKS for still-patent AVM residuals after the initial GKS procedure. Clinical follow-up ranged from 24 to 196 months, with a mean of 78 months (median 51 months) after the initial GKS.

Results

Following GKS, 19 patients (61.3%) had a total AVM obliteration on angiography. In 7 patients (22.6%), no flow voids were observed on MRI but angiographic confirmation was not available. In 5 patients (16.1%), the AVMs remained patent. A small nidus volume was significantly associated with increased AVM obliteration rate. Thirteen patients (41.9%) developed radiation-induced imaging changes: 11 were asymptomatic (35.5%), 1 had only headache (3.2%), and 1 developed seizure and neurological deficits (3.2%). Two patients each had 1 hemorrhage during the latency period (116.5 risk years), yielding an annual hemorrhage rate of 1.7% before AVM obliteration.

Conclusions

The decision to treat asymptomatic AVMs, and if so, which treatment approach to use, remain the subject of debate. GKS as a minimally invasive procedure appears to achieve a reasonable outcome with low procedure-related morbidity. In those patients with incidental AVMs, the benefits as well as the risks of radiosurgical intervention will only be fully defined with long-term follow-up.

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Nohra Chalouhi, Cory D. Bovenzi, Vismay Thakkar, Jeremy Dressler, Pascal Jabbour, Robert M. Starke, Sonia Teufack, L. Fernando Gonzalez, Richard Dalyai, Aaron S. Dumont, Robert Rosenwasser and Stavropoula Tjoumakaris

Object

Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. The need for long-term imaging follow-up was recently investigated. This study assessed the diagnostic yield of long-term digital subtraction angiography (DSA) follow-up and determined predictors of delayed aneurysm recurrence and retreatment.

Methods

Inclusion criteria were as follows: 1) available short-term and long-term (> 36 months) follow-up DSA images, and 2) no or only minor aneurysm recurrence (not requiring further intervention, i.e., < 20%) documented on short-term follow-up DSA images.

Results

Of 209 patients included in the study, 88 (42%) presented with subarachnoid hemorrhage. On shortterm follow-up DSA images, 158 (75%) aneurysms showed no recurrence, and 51 (25%) showed minor recurrence (< 20%, not retreated). On long-term follow-up DSA images, 124 (59%) aneurysms showed no recurrence, and 85 (41%) aneurysms showed recurrence, of which 55 (26%) required retreatment. In multivariate analysis, the predictors of recurrence on long-term follow-up DSA images were as follows: 1) larger aneurysm size (p = 0.001), 2) male sex (p = 0.006), 3) conventional coil therapy (p = 0.05), 4) aneurysm location (p = 0.01), and 5) a minor recurrence on short-term follow-up DSA images (p = 0.007). Ruptured aneurysm status was not a predictive factor. The sensitivity of short-term follow-up DSA studies was only 40.0% for detecting delayed aneurysm recurrence and 45.5% for detecting delayed recurrence requiring further treatment.

Conclusions

The results of this study highlight the importance of long-term angiographic follow-up after coil therapy for ruptured and unruptured intracranial aneurysms. Predictors of delayed recurrence and retreatment include large aneurysms, recurrence on short-term follow-up DSA images (even minor), male sex, and conventional coil therapy.

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Christopher R. Durst, Robert M. Starke, John R. Gaughen Jr., Scott Geraghty, K. Derek Kreitel, Ricky Medel, Nicholas Demartini, Kenneth C. Liu, Mary E. Jensen and Avery J. Evans

Object

The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique.

Methods

The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported.

Results

The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0–2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%.

Conclusions

The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms.

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Robert M. Starke, Dale Ding, Christopher R. Durst, R. Webster Crowley and Kenneth C. Liu

Dissecting vertebral artery (VA) aneurysms are difficult to obliterate when the parent artery cannot be safely occluded. In this video, we demonstrate a combined microsurgical and endovascular treatment technique for a ruptured, dissecting VA aneurysm incorporating the origin of the posterior inferior cerebellar artery (PICA). We first performed a PICA-PICA side-to-side bypass to preserve flow through the right PICA. An endovascular approach was then utilized to embolize the proximal portion of the aneurysm from the right VA and the distal portion of the aneurysm from the left VA.

The video can be found here: http://youtu.be/dkkKsX2BiJI.

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Robert M. Starke, John A. Jane Jr., Ashok R. Asthagiri and John A. Jane Sr.

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Robert M. Starke, Colin J. Przybylowski, Mukherjee Sugoto, Francis Fezeu, Ahmed J. Awad, Dale Ding, James H. Nguyen and Jason P. Sheehan

OBJECT

Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm.

METHODS

The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS.

RESULTS

After a mean follow-up of 6.5 years (range 0.5–21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91–7.45; p < 0.001), history of radiotherapy (HR 12.06, 95% CI 2.04–71.27; p = 0.006), and tumor volume greater than 14 cm3 (HR 6.86, 95% CI 0.88–53.36; p = 0.066). In those patients with detailed clinical follow-up (n = 64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and deteriorated in 11 patients (17%). In multivariate analysis, the factors predictive of new or worsening neurological function were history of surgery (OR 3.00, 95% CI 1.13–7.95; p = 0.027), presentation with any CN deficit from III to VI (OR 3.94, 95% CI 1.49–10.24; p = 0.007), and decreasing maximal dose (OR 0.76, 95% CI 0.63–0.93; p = 0.007). Tumor progression was present in 64% of patients with new or worsening neurological decline.

CONCLUSIONS

Stereotactic radiosurgery affords a reasonable rate of tumor control for large skull base meningiomas and does so with a low incidence of neurological deficits. Those with a tumor less than 14 cm3 in volume and without presenting CN deficit from III to VI were more likely to have effective tumor control.

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Ching-Jen Chen, Cheng-Chia Lee, Dale Ding, Robert M. Starke, Srinivas Chivukula, Chun-Po Yen, Shayan Moosa, Zhiyuan Xu, David Hung-Chi Pan and Jason P. Sheehan

OBJECT

The goal of this study was to evaluate the obliteration rate of intracranial dural arteriovenous fistulas (DAVFs) in patients treated with stereotactic radiosurgery (SRS), and to compare obliteration rates between cavernous sinus (CS) and noncavernous sinus (NCS) DAVFs, and between DAVFs with and without cortical venous drainage (CVD).

METHODS

A systematic literature review was performed using PubMed. The CS DAVFs and the NCS DAVFs were categorized using the Barrow and Borden classification systems, respectively. The DAVFs were also categorized by location and by the presence of CVD. Statistical analyses of pooled data were conducted to assess complete obliteration rates in CS and NCS DAVFs, and in DAVFs with and without CVD.

RESULTS

Nineteen studies were included, comprising 729 patients harboring 743 DAVFs treated with SRS. The mean obliteration rate was 63% (95% CI 52.4%–73.6%). Complete obliteration for CS and NCS DAVFs was achieved in 73% and 58% of patients, respectively. No significant difference in obliteration rates between CS and NCS DAVFs was found (OR 1.72, 95% CI 0.66–4.46; p = 0.27). Complete obliteration in DAVFs with and without CVD was observed in 56% and 75% of patients, respectively. A significantly higher obliteration rate was observed in DAVFs without CVD compared with DAVFs with CVD (OR 2.37, 95% CI 1.07–5.28; p = 0.03).

CONCLUSIONS

Treatment with SRS offers favorable rates of DAVF obliteration with low complication rates. Patients harboring DAVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using SRS.