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Gakushi Yoshikawa, Kazuya Nagata, Shunsuke Kawamoto, and Kazuo Tsutsumi

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Fumi Higuchi, Shunsuke Kawamoto, Yoshihiro Abe, Phyo Kim, and Keisuke Ueki

Object

Gamma Knife surgery (GKS) has gained increasing relevance in the treatment of metastatic brain tumors, but many metastatic tumors contain a large cystic component and often exceed the size limit for GKS. For such lesions, the authors adopted a procedure in which stereotactic aspiration is first performed and followed immediately by GKS on the same day. In this paper, the authors describe this 1-day combined procedure and evaluate its efficacy.

Methods

Between 2005 and 2010, 25 cystic metastases in 25 patients were treated at Dokkyo Medical University. The patients first underwent MRI and stereotactic aspiration of the cyst while stationary in a Leksell stereotactic frame; immediately afterward, the patients underwent a second MR imaging session and Gamma Knife treatment. Tumor volume reduction, tumor control rate, and overall survival were examined.

Results

Tumor volume, including the cystic component, decreased from 8.0–64.2 cm3 (mean 20.3 cm3) to 3.0–36.2 cm3 (mean 10.3 cm3) following aspiration, and the volume of 24 of 25 lesions decreased to less than 16.6 cm3, which is equivalent to the volume of a 3.16-cm sphere. At least 20 Gy was delivered to the entire lesion in 24 of 25 cases. Good tumor control was obtained in 16 of 21 cases that could be evaluated during a median follow-up period of 11 months (range 1–27 months); however, reaccumulation of cyst contents was observed in 2 patients who required Ommaya reservoir placement.

Conclusions

The 1-day aspiration plus GKS procedure is an effective and time-efficient treatment for large cystic brain metastases.

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Keisuke Maruyama, Masahiro Shin, Masao Tago, Hiroki Kurita, Shunsuke Kawamoto, Akio Morita, and Takaaki Kirino

Object. The purpose of this study was to evaluate the safety and efficacy of gamma knife surgery (GKS) for the treatment of arteriovenous malformations (AVMs) involving the corpus callosum.

Methods. Thirty-two patients aged from 7 to 65 years (median 25 years) with AVMs of the corpus callosum underwent GKS between 1990 and 2002. The maximum AVM diameter was more than 3 cm in 11 patients (34%). The AVM volume ranged from 0.1 to 19.1 cm3 (median 1.6 cm3). The median dose to the AVM margin was 20 Gy (range 17–28 Gy). Patients were followed for 1 to 12 years (median 9 years). The angiographically confirmed actuarial obliteration rate was 64% and 74% at 4 and 6 years, respectively. Younger patient age (p < 0.05) and lower radiosurgery-based grading score (calculated from the patient age and AVM volume; p < 0.01) were the significant factors affecting successful AVM obliteration. No patient suffered a hemorrhage after GKS, although 28 patients (88%) had a history of hemorrhage from their AVMs. Radiation-induced neurological deficit was observed only in one patient (3%) who had undergone previous radiotherapy (50 Gy). No patient experienced complications of occlusion or stenosis of the normal vascular structures adjacent to the AVM.

Conclusions. Gamma knife surgery is a safe and effective treatment for selected patients with AVMs involving the corpus callosum, and it carries a low risk of damaging adjacent critical vascular structures. Even ruptured AVMs with relatively large diameter can be successfully treated, especially in younger patients, with minimal morbidity and a low risk of repeated hemorrhage.

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Hiroki Kurita, Keisuke Ueki, Masahiro Shin, Shunsuke Kawamoto, Tomio Sasaki, Masao Tago, and Takaaki Kirino

Object. The goal of this study was to determine the prevalence, characteristics, and radiosurgical outcomes of headaches associated with occipital arteriovenous malformations (AVMs).

Methods. The authors reviewed the medical records of 37 consecutive patients with occipital AVMs who had been treated by radiosurgery to identify the radiological features of the AVMs before and after treatment and the clinical features and outcomes of headaches described in accordance with the criteria of the International Headache Society (IHS).

Thirty-six patients (97.3%) were followed for a mean period of 46.6 months. The median volume of the AVMs was 1.9 cm3, to which a mean radiation dose of 21.6 Gy was delivered. In the entire study group, periodic headaches were found in 17 patients (45.9%), of whom seven (18.9%) suffered from migraines with the characteristic visual aura. Migraine was predominantly found in patients with right-sided (p = 0.038) or laterally located (p = 0.025) AVMs. Factors associated with a higher incidence of any type of headache included larger nidus volume (p = 0.02), tortuous change of feeding artery (p = 0.036), and cortical drainage with reflux in the superior sagittal sinus (p = 0.032). The actuarial rate of angiographic obliteration was 71.6% at 3 years. Headaches resolved or improved in 12 (70.6%) of 17 patients, including six (85.7%) of seven with migraine. The outcome of headache closely correlated with the obliteration results of the AVM (p = 0.002).

Conclusions. A portion of occipital AVMs do cause headaches that satisfy the current IHS criteria for migraine, and the prevalence varies by the topography of the lesion. Radiosurgery can resolve headaches in the majority of treated patients.

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Shunsuke Kawamoto, Kazuo Tsutsumi, Gakushi Yoshikawa, Mune-hisa Shinozaki, Kyoko Yako, Kazuya Nagata, and Keisuke Ueki

Object

The head-shaking method combined with cisternal irrigation has been proposed to be effective in preventing cerebral vasospasm after subarachnoid hemorrhage (SAH) by facilitating rapid washout of the clot from the subarachnoid space. This study was conducted to evaluate the effectiveness of this method.

Methods

The inclusion criteria included the following: 1) Fisher Grade 3 SAH on admission computerized tomography (CT) scans; 2) aneurysm secured within 48 hours of SAH onset; and 3) no focal deficit and ability to obey commands within 24 hours postsurgery. Two hundred thirty patients treated between 1994 and 2002 fulfilled the criteria. Because only one machine was available and it required 1 month of maintenance every other month, 114 patients underwent irrigation combined with the head-shaking method (head-shaking group), whereas the remaining 116 patients received cisternal irrigation alone (control group). There were no significant differences in sex, age, site of aneurysm, or preoperative grade between the two groups.

The incidence of symptomatic vasospasm with or without infarction, cerebral infarction on CT scans, and permanent ischemic neurological deficit was 25.7, 17.7, and 8.8%, respectively, in the control group and 15.2, 4.5, and 2.7% in the head-shaking group. The difference was statistically significant for symptomatic vasospasm, cerebral infarction, and permanent ischemic neurological deficit (p < 0.05). In a multivariate backward stepwise logistic regression analysis, absence of head shaking was the only variable that was predictive of permanent ischemic neurological deficit (p = 0.061). The outcomes evaluated using the modified Rankin Scale were better in the head-shaking group (p = 0.051).

Conclusions

The head-shaking method significantly reduced the incidence of symptomatic vasospasm, cerebral infarction, and permanent ischemic neurological deficit and improved the clinical outcomes in patients who underwent cisternal irrigation therapy after aneurysmal SAH.

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Masahiro Shin, Hiroki Kurita, Tomio Sasaki, Shunsuke Kawamoto, Masao Tago, Nobutaka Kawahara, Akio Morita, Keisuke Ueki, and Takaaki Kirino

Object. The long-term outcome of stereotactic radiosurgery for cavernous sinus (CS) meningiomas is not fully understood. The authors retrospectively reviewed their experience with 40 CS meningiomas treated with gamma knife radiosurgery.

Methods. Follow-up periods for the 40 patients ranged from 12 to 123 months (median 42 months), and the overall tumor control rates were 86.4% at 3 years and 82.3% at 10 years. Factors associated with tumor recurrence in univariate analysis were histological malignancy (p < 0.0001), partial treatment (p < 0.0001), suprasellar tumor extension (p = 0.0201), or extension in more than three directions outside the CS (p = 0.0345). When the tumor was completely covered with a dose to the margin that was higher than 14 Gy (Group A, 22 patients), no patient showed recurrence within the median follow-up period of 37 months. On the other hand, when a part of the tumor was treated with 10 to 12 Gy (Group B, 15 patients) or did not receive radiation therapy (Group C, three patients), the recurrence rates were 20% and 100%, respectively. Neurological deterioration was seen in nine patients, but all symptoms were transient or very mild.

Conclusions. The data indicate that stereotactic radiosurgery can control tumor growth if the whole mass can be irradiated by dosages of more than 14 Gy. When optimal radiosurgical planning is not feasible because of a tumor's large size, irregular shape, or proximity to visual pathways, use of limited surgical resection before radiosurgery is the best option and should provide sufficient long-term tumor control with minimal complications.

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Masahiro Shin, Keisuke Maruyama, Hiroki Kurita, Shunsuke Kawamoto, Masao Tago, Atsuro Terahara, Akio Morita, Keisuke Ueki, Kintomo Takakura, and Takaaki Kirino

Object. A large number of clinical studies have been made on treatment outcomes of radiosurgery for arteriovenous malformations (AVMs), but the reported obliteration rates following this treatment vary significantly, perhaps reflecting the different methods and timings of the imaging studies used.

Methods. The authors retrospectively analyzed their experience with gamma knife surgery in 400 patients with AVMs (follow-up period 1–135 months, median 65 months), with special reference to the imaging modality used in each case. The calculated obliteration rates varied from 68.2 to 92%, depending on imaging modality and timing of evaluation. When only unquestionable imaging data such as demonstrations of a residual nidus on computerized tomography (CT) or magnetic resonance (MR) images or findings on angiograms were used in the calculation, the obliteration rates were 72% at 3 years and 87.3% at 5 years. Factors leading to a better obliteration rate were previous hemorrhage (p = 0.0084), smaller nidus (p = 0.0023), and higher radiation dose to the lesion's margin (p = 0.0495), as determined in a multivariate analysis. Factors leading to an earlier obliteration of the nidus were male sex (p = 0.0001), previous hemorrhage (p = 0.0039), smaller nidus diameter (p = 0.0006), and dose planning using angiography alone (p = 0.0201).

Conclusions. After the introduction of CT and MR images into dose planning, the conformity and selectivity of dosimetry improved remarkably, although the latency intervals until obliteration were prolonged. Imaging outcomes for AVMs should be evaluated using data provided by longer follow-up periods. The timing of additional treatments for residual AVMs should be decided cautiously, considering the size of the AVM, the patient age and sex, and the history of hemorrhage before radiosurgery.

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Tomio Sasaki, Hiroki Kurita, Isamu Saito, Shunsuke Kawamoto, Shigeru Nemoto, Atsuro Terahara, Takaaki Kirino, and Kintomo Takakura

Object. Because arteriovenous malformations (AVMs) in the basal ganglia and thalamus are difficult to treat, the authors conducted a retrospective study to determine the best management strategy for these lesions.

Methods. The authors reviewed the management and outcome in 101 patients with AVMs treated between 1971 and 1995. In 15 conservatively treated patients, hemorrhage occurred in 71.4% (annual rate 11.4%), and the morbidity and mortality rates were 7.1% and 42.9%, respectively, during a mean follow-up period of 6.6 years. Total microsurgical resection was performed in 15 patients with no mortality resulting, but motor function deteriorated permanently in three of them (20%). Postoperative morbidity correlated well with the location of the AVM and with preoperative motor function. In cases of lenticular AVMs without motor weakness, a postoperative decrease in motor function was significantly more common than in the remaining patients. In patients with motor weakness before surgery, AVMs in the thalamus or caudate nucleus were successfully resected. Among 66 patients treated with gamma knife radiosurgery, three had permanent radiation-induced neurological deficits, and three others experienced bleeding (new bleeding in one case and rebleeding in two). The treatment-associated morbidity rate was 6.7%, and the actuarial rate of complete obliteration was 85.7% at 2.5 years. In five patients treated with embolization alone, the morbidity and mortality rates associated with the procedure or bleeding were 40% and 20%, respectively. The morbidity and mortality rates in the pre—gamma knife era were 22.2% and 22.2%, whereas those for the post-gamma knife era are currently 10.4% and 1.5%, respectively.

Conclusions. These results indicate that conservatively treated AVMs are more likely to bleed and thus produce a high incidence of patient mortality. Multimodal treatment including radiosurgery, microsurgery, and embolization improved clinical outcomes by making it possible to treat difficult cases successfully.

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Masahiro Shin, Shunsuke Kawamoto, Hiroki Kurita, Masao Tago, Tomio Sasaki, Akio Morita, Keisuke Ueki, and Takaaki Kirino

Object. To obtain information essential to the decision to perform radiosurgery for arteriovenous malformations (AVMs) in children and adolescents, the authors retrospectively analyzed their experience with gamma knife surgery for AVMs in 100 patients ranging in age from 4 to 19 years.

Methods. Follow-up periods ranged from 6 to 124 months (median 71 months), and the actuarial obliteration rates demonstrated by angiography were 84.1, 89.4, and 94.7% at 3, 4, and 5 years, respectively. Factors associated with better obliteration rates in univariate analysis included the following: a patient age of 12 years or younger; a mean nidus diameter of 2 cm or less; a nidus volume of 3.8 cm3 or less; a maximum diameter of the nidus less than 3 cm; and a Spetzler—Martin grade of III or less. Radiation-induced neuropathy was seen in four patients, and the risk factors were considered to be a nidus in the brainstem and a maximum radiation dose greater than 40 Gy. Hemorrhage developed during the latency interval in four patients, and one patient with a cerebellar AVM died of the hemorrhage. The annual bleeding rate was 1.5%. Feeding arteries located in the posterior cranial fossa and an AVM nidus located in the cerebellum were significantly associated with the risk of hemorrhage. After angiographically verified obliteration of the nidus, 51 patients continued to be observed from 1 to 110 months (median 67 months); hemorrhage developed in one patient 38 months after nidus obliteration.

Conclusions. Radiosurgery is an acceptable treatment for small AVMs in children and adolescents in whom a higher obliteration rate can be achieved with lower risks of interval hemorrhage compared with the reported results in the general population. Careful follow-up observation seems to be required, however, even after angiographically verified obliteration.