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Arteriovenous malformations and radiosurgery

Douglas Kondziolka, Hideyuki Kano and L. Dade Lunsford

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Editorial

Trigeminal neuralgia

Kim J. Burchiel

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Gillian Harrison, Hideyuki Kano, L. Dade Lunsford, John C. Flickinger and Douglas Kondziolka

OBJECT

The reported tumor control rates for meningiomas after stereotactic radiosurgery (SRS) are high; however, early imaging assessment of tumor volumes may not accurately predict the eventual tumor response. The objective in this study was to quantitatively evaluate the volumetric responses of meningiomas after SRS and to determine whether early volume responses are predictive of longer-term tumor control.

METHODS

The authors performed a retrospective review of 252 patients (median age 56 years, range 14–87 years) who underwent Gamma Knife radiosurgery between 2002 and 2010. All patients had evaluable pre- and postoperative T1-weighted contrast-enhanced MRIs. The median baseline tumor volume was 3.5 cm3 (range 0.2–33.8 cm3) and the median follow-up was 19.5 months (range 0.1–104.6 months). Follow-up tumor volumes were compared with baseline volumes. Tumor volume percent change and the tumor volume rate of change were compared at 3-month intervals. Eventual tumor responses were classified as progressed for > 15% volume change, regressed for ≤ 15% change, and stable for ± 15% of baseline volume at time of last follow-up. Volumetric data were compared with the final tumor status by using univariable and multivariable logistic regression.

RESULTS

Tumor volume regression (median decrease of −40.2%) was demonstrated in 168 (67%) patients, tumor stabilization (median change of −2.7%) in 67 (26%) patients, and delayed tumor progression (median increase of 104%) in 17 (7%) patients (p < 0.001). Tumors that eventually regressed had an average volume reduction of −18.2% at 3 months. Tumors that eventually progressed all demonstrated volume increase by 6 months. Transient progression was observed in 15 tumors before eventual decrease, and transient regression was noted in 6 tumors before eventual volume increase.

CONCLUSIONS

The volume response of meningiomas after SRS is dynamic, and early imaging estimations of the tumor volume may not correlate with the final tumor response. However, tumors that ultimately regressed tended to respond in the first 3 months, whereas tumors that ultimately progressed showed progression within 6 months.

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Editorial

Relationship between tinnitus and surgical options for vestibular schwannomas

Douglas Kondziolka and Hideyuki Kano

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Jason Sheehan and Chun Po Yen

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Mohamed Samy Elhammady and Roberto C. Heros

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Ajay Niranjan, Ahmed Kashkoush, Hideyuki Kano, Edward A. Monaco III, John C. Flickinger and L. Dade Lunsford

OBJECTIVE

Seizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control.

METHODS

Patients with AVM who presented with a history of seizure and underwent SRS at the authors’ institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6–295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up.

RESULTS

Seizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0–27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4–23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15–0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16–0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test).

CONCLUSIONS

This study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.

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L. Dade Lunsford, Aftab A. Khan, Ajay Niranjan, Hideyuki Kano, John C. Flickinger and Douglas Kondziolka

Object

A retrospective study was conducted to reassess the benefit and safety of stereotactic radiosurgery (SRS) in patients with solitary cerebral cavernous malformations (CCMs) that bleed repeatedly and are poor candidates for surgical removal.

Methods

Between 1988 and 2005 at the University of Pittsburgh, the authors performed SRS in 103 evaluable patients (57 males and 46 females) with solitary symptomatic CCMs. The mean patient age was 39.3 years. Ninety-eight percent of these patients had experienced 2 or more hemorrhages associated with new neurological deficits. Seventeen patients (16.5%) had undergone attempted resection before radiosurgery. Ninety-three CCMs were located in deep brain structures and 10 were in subcortical lobar areas of functional brain importance. The median malformation volume was 1.31 ml, and the median tumor margin dose was 16 Gy.

Results

The follow-up ranged from 2 to 20 years. The annual hemorrhage rate—that is, a new neurological deficit associated with imaging evidence of a new hemorrhage—before SRS was 32.5%. After SRS 22 hemorrhages were observed within 2 years (10.8% annual hemorrhage rate) and 4 hemorrhages were observed after 2 years (1.06% annual hemorrhage rate). The risk of hemorrhage from a CCM was significantly reduced after radiosurgery (p < 0.0001). Overall, new neurological deficits due to adverse radiation effects following SRS developed in 14 patients (13.5%), with most occurring early in our experience. Modifications in technique (treatment volume within the T2-weighted MR imaging–defined margin, use of MR imaging, and dose reduction for CCM in critical brainstem locations) further reduced risks after SRS.

Conclusions

Data in this study provide further evidence that SRS is a relatively safe procedure that reduces the rebleeding rate for CCMs located in high-surgical-risk areas of the brain.