BACKGROUND: Repeat stereotactic radiosurgery (SRS) for persistent cerebral arteriovenous malformation (AVM) has generally favorable patient outcomes. However, reporting studies are limited by small patient numbers and single-institution biases. The purpose of this study was to provide the combined experience of multiple centers, in an effort to fully define the role of repeat SRS for patients with arteriovenous malformation. METHODS: This multicenter, retrospective cohort study included patients treated with repeat, single-fraction SRS between 1987 and 2022. Follow-up began at repeat SRS. The primary outcome was a favorable patient outcome, defined as a composite of nidus obliteration in the absence of hemorrhage or radiation-induced neurological deterioration. Secondary outcomes were obliteration, hemorrhage risk, and symptomatic radiation-induced changes. Competing risk analysis was performed to compute yearly rates and identify predictors for each outcome. RESULTS: The cohort comprised 505 patients (254 [50.3%] males; median [interquartile range] age, 34 [15] years) from 14 centers. The median clinical and magnetic resonance imaging follow-up was 52 (interquartile range, 61) and 47 (interquartile range, 52) months, respectively. At last follow-up, favorable outcome was achieved by 268 (53.1%) patients (5-year probability, 50% [95% CI, 45%-55%]) and obliteration by 300 (59.4%) patients (5-year probability, 56% [95% CI, 51%-61%]). Twenty-eight patients (5.6%) experienced post-SRS hemorrhage with an annual incidence rate of 1.38 per 100 patient-years. Symptomatic radiation-induced changes were evident in 28 (5.6%) patients, with most occurring in the first 3 years. Larger nidus volumes (between 2 and 4 cm3, subdistribution hazard, 0.61 [95% CI, 0.44-0.86]; P=0.005; >4 cm3, subdistribution hazard, 0.47 [95% CI, 0.32-0.7]; P<0.001) and brainstem/basal ganglia involvement (subdistribution hazard, 0.6 [95% CI, 0.45-0.81]; P<0.001) were associated with reduced probability of favorable outcome. CONCLUSIONS: Repeat SRS confers reasonable obliteration rates with a low complication risk. With most complications occurring in the first 3 years, extending the latency period to 5 years generally increases the rate of favorable patient outcomes and reduces the necessity of a third intervention.

• MeSH
• dospělí MeSH
• intrakraniální arteriovenózní malformace * diagnostické zobrazování   radioterapie   chirurgie   MeSH
• lidé MeSH
• následné studie MeSH
• radiochirurgie * škodlivé účinky   metody   MeSH
• retrospektivní studie MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH

OBJECTIVE: The optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. One approach is volume-staged stereotactic radiosurgery (VS-SRS). The authors previously reported efficacy of VS-SRS for large AVMs in a multiinstitutional cohort; here they focus on risk of symptomatic adverse radiation effects (AREs). METHODS: This is a multicentered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM, with volume stages separated by intervals of 3-6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. The authors evaluated permanent, transient, and total ARE events that were symptomatic. RESULTS: Patients received 2-4 total volume stages. The median age was 33 years at the time of the first SRS volume stage, and the median follow-up was 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cm3 (range 7.7-94.4 cm3), with a median margin dose per stage of 17 Gy (range 12-20 Gy). A total of 64 patients (25%) experienced an ARE, of which 19 were permanent. Rather than volume, maximal linear dimension in the Z (craniocaudal) dimension was associated with toxicity; a threshold length of 3.28 cm was associated with an ARE, with a 72.5% sensitivity and a 58.3% specificity. In addition, parietal lobe involvement for superficial lesions and temporal lobe involvement for deep lesions were associated with an ARE. CONCLUSIONS: Size remains the dominant predictor of toxicity following SRS, but overall rates of AREs were lower than anticipated based on baseline features, suggesting that dose and size were relatively dissociated through volume staging. Further techniques need to be assessed to optimize outcomes.

• MeSH
• dospělí MeSH
• intrakraniální arteriovenózní malformace * diagnostické zobrazování   radioterapie   chirurgie   MeSH
• lidé MeSH
• následné studie MeSH
• prospektivní studie MeSH
• radiochirurgie * škodlivé účinky   metody   MeSH
• retrospektivní studie MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH

BACKGROUND: Although complete nidal obliteration of brain arteriovenous malformations (AVM) is generally presumed to represent durable cure, postobliteration hemorrhage, and AVM recurrence have become increasingly recognized phenomena. The goal of the study was to define hemorrhage and nidal recurrence risks of obliterated AVMs treated with stereotactic radiosurgery (SRS). METHODS: This is a retrospective cohort study from the International Radiosurgery Research Foundation comprising AVM patients treated between 1987 and 2020. Patients with AVM obliteration on digital subtraction angiography (DSA) were included. Outcomes were (1) hemorrhage and (2) AVM recurrence. Follow-up duration began at the time of AVM obliteration and was censored at subsequent hemorrhage, AVM recurrence, additional AVM treatment, or loss to follow-up. Annualized risk and survival analyses were performed. A sensitivity analysis comprising patients with AVM obliteration on magnetic resonance imaging or DSA was also performed for postobliteration hemorrhage. RESULTS: The study cohort comprised 1632 SRS-treated patients with AVM obliteration on DSA. Pediatric patients comprised 15% of the cohort, and 42% of AVMs were previously ruptured. The mean imaging follow-up after AVM obliteration was 22 months. Among 1607 patients with DSA-confirmed AVM obliteration, 16 hemorrhages (1.0%) occurred over 2223 patient-years of follow-up (0.72%/y). Of the 1543 patients with DSA-confirmed AVM obliteration, 5 AVM recurrences (0.32%) occurred over 2071 patient-years of follow-up (0.24%/y). Of the 16 patients with postobliteration hemorrhage, AVM recurrence was identified in 2 (12.5%). In the sensitivity analysis comprising 1939 patients with post-SRS AVM obliteration on magnetic resonance imaging or DSA, 16 hemorrhages (0.83%) occurred over 2560 patient-years of follow-up (0.63%/y). CONCLUSIONS: Intracranial hemorrhage and recurrent arteriovenous shunting after complete nidal obliteration are rare in AVM patients treated with SRS, and each phenomenon harbors an annual risk of <1%. Although routine postobliteration DSA cannot be recommended to SRS-treated AVM patients, long-term neuroimaging may be advisable in these patients.

• MeSH
• dítě MeSH
• intrakraniální arteriovenózní malformace * diagnostické zobrazování   radioterapie   chirurgie   MeSH
• intrakraniální krvácení etiologie   MeSH
• lidé MeSH
• mozek patologie   MeSH
• následné studie MeSH
• radiochirurgie * škodlivé účinky   MeSH
• retrospektivní studie MeSH
• výsledek terapie MeSH
• Check Tag
• dítě MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

• MeSH
• intrakraniální aneurysma * chirurgie   etiologie   patofyziologie   MeSH
• intrakraniální arteriovenózní malformace * chirurgie   diagnóza   patofyziologie   MeSH
• ischemická cévní mozková příhoda * chirurgie   patofyziologie   MeSH
• lidé MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• přehledy MeSH

AIM: To report on patients who underwent surgical treatment of arteriovenous malformations (AVMs) at our institution. METHODS: This retrospective single-center case series enrolled the patients who underwent surgical treatment of pial AVM at the Department of Neurosurgery, University Hospital Brno, between 2005 and 2019. The data are summarized as descriptive statistics presenting basic characteristics in all the patients and in sex or age subgroups. RESULTS: Fifty patients were enrolled. The majority of AVMs were of Spetzler-Martin grade II (n=27; 54%), localized supratentorialy (n=43; 86%), and half of AVMs were ruptured. A total resection was performed in 48 patients (96%), and a good overall outcome was achieved in 44 patients (88%). Surgery-associated morbidity was 2%, and the mortality rate was 0% due to meticulous selection of patients for surgical treatment. CONCLUSION: Microsurgery is an appropriate method of treatment for S-M grade I-III pial AVMs. Microsurgery may be used to treat the majority of small-nidus AVMs with a low mortality and morbidity, when precisely planned and performed by an expert vascular team. The meticulous selection of patients for surgical treatment is crucial.

• MeSH
• intrakraniální arteriovenózní malformace * chirurgie   MeSH
• lidé MeSH
• mikrochirurgie MeSH
• retrospektivní studie MeSH
• terapeutická embolizace * MeSH
• výsledek terapie MeSH
• výzkum MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: Optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. Volume-staged stereotactic radiosurgery (VS-SRS) provides an effective option for these high-risk lesions, but optimizing treatment for these recalcitrant and rare lesions has proven difficult. METHODS: This is a multi-centered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM with volume stages separated by intervals of 3-6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. We evaluated near complete response (nCR), obliteration, cure, and overall survival. RESULTS: With a median age of 33 years old at the time of first SRS volume stage, patients received 2-4 total volume stages and a median follow up of 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cc (range: 7.7-94.4 cc) with a median margin dose per stage of 17 Gy (range: 12-20 Gy). Total AVM volume, margin dose per stage, compact nidus, lack of prior embolization, and lack of thalamic location involvement were all associated with improved outcomes. Dose >/= 17.5 Gy was strongly associated with improved rates of nCR, obliteration, and cure. With dose >/= 17.5 Gy, 5- and 10-year cure rates were 33.7% and 76.8% in evaluable patients compared to 23.7% and 34.7% of patients with 17 Gy and 6.4% and 20.6% with <17 Gy per volume-stage (p = 0.004). Obliteration rates in diffuse nidus architecture with <17 Gy were particularly poor with none achieving obliteration compared to 32.3% with doses >/= 17 Gy at 5 years (p = 0.007). Comparatively, lesions with a compact nidus architecture exhibited obliteration rates at 5 years were 10.7% vs 9.3% vs 26.6% for dose >17 Gy vs 17 Gy vs >/=17.5 Gy. CONCLUSION: VS-SRS is an option for upfront treatment of large AVMs. Higher dose was associated with improved rates of nCR, obliteration, and cure suggesting that larger volumetric responses may facilitate salvage therapy and optimize the chance for cure.

• MeSH
• dospělí MeSH
• intrakraniální arteriovenózní malformace * radioterapie   chirurgie   MeSH
• lidé MeSH
• následné studie MeSH
• prospektivní studie MeSH
• radiochirurgie * MeSH
• retrospektivní studie MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH

• MeSH
• intrakraniální arteriovenózní malformace chirurgie   diagnostické zobrazování   MeSH
• lidé MeSH
• mladiství MeSH
• neurozobrazování metody   MeSH
• terapeutická embolizace metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• mladiství MeSH
• ženské pohlaví MeSH
• Publikační typ
• kazuistiky MeSH

Autoři uvádějí monocentrickou retrospektivní studii souboru 27 pacientů operovaných pro neprasklou piální arteriovenózní malformaci (AVM) během let 1999–2017. Cílem bylo porovnat naše výsledky s výsledky větších zahraničních studií a vyvodit z toho patřičné závěry. U všech pacientů byla provedena radikální resekce AVM a zhodnocen jejich klinický stav modifikovanou Rankinovou škálou před operací a po operaci se sledováním v průměru 6 let. V souboru byly zastoupeny kategorie I–IV piálních AVM dle Spetzler-Martinovy škály. Po resekci se šest pacientů zlepšilo, jeden zhoršil a ostatní zůstali ve stejném stavu jako před operací. Morbidita našeho souboru činí 3,7 %, mortalita 0 %. Po 16 letech sledování se ani u jednoho pacienta neprokázala recidiva či reziduum malformace. V porovnání se zahraničními studiemi jsou naše výsledky u každého typu AVM srovnatelné, a proto lze doporučit u neprasklých AVM Spetzler-Martin I–II mikrochirurgické řešení, pro neprasklé AVM Spetzler-Martin III mikrochirurgický přístup s možným doplněním alternativní metodou embolizace či radioterapie a u AVM Spetzler-Martin IV–V spíše observaci.

The authors present a monocentric retrospective study of a group of 27 patients operated for non-ruptured brain arteriovenous malformation (AVM) during years 1999–2017. The aim was to compare our results with the results of larger international studies and to draw appropriate conclusions. All patients underwent radical resection of the AVM and their clinical status was evaluated using the modified Rankin scale before and after the surgery with an average 6-year follow-up. The group was represented by the AVM´s Spetzler-Martin Scale I–IV. After resection, six patients improved, one deteriorated, and the others remained in the same condition as before surgery. Our morbidity was 3.7 % and mortality was 0 %. After 16 years of follow-up, no recurrence or residual malformation were detected in any patient. Compared to foreign studies, our results for all types of AVM´s are comparable and, therefore, for the unruptured the AVM´s Spetzler-Martin I–II microsurgical approach, for the unruptured AVM´s Spetzler-Martin III microsurgical approach with possible complementary alternatives of embolization or radiotherapy and for the AVM´s Spetzler-Martin IV–V rather observation can be recommended.

• Klíčová slova
• škála Spetzler-Martin,
• MeSH
• intrakraniální arteriovenózní malformace * chirurgie   MeSH
• lidé MeSH
• mikrochirurgie metody   MeSH
• neurochirurgické výkony metody   MeSH
• retrospektivní studie MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH

Background The treatment of brain arteriovenous malformations (AVMs) has been studied extensively. With the use of the Spetzler-Martin (S-M) grading system, patients can be informed appropriately about their possible surgical risks. This does not hold true for their neuropsychological sequelae, which have not been studied widely. We evaluated the neuropsychological outcome of our patients treated for brain AVMs. Methods Of 113 patients treated for a brain AVM between 2001 and 2009, 66 patients were enrolled in the study. All patients underwent treatment at our institution and neuropsychological testing 2 years later using a test battery constructed specifically for this study. A control group consisted of 10 subjects without any neurologic disease. Results When the whole cohort was analyzed, no significant differences were found between the groups distinguished by hemorrhage, gender, or hemispheric dominance. Patients with S-M IV and V scores fared significantly worse than patients with S-M I to III. Patients who presented with epilepsy scored lower than patients presenting with other symptomatology, but the difference had only borderline significance. When we analyzed patients according to the presence or absence of obliteration after treatment and compared these with the control group, we found no significant differences. When the patients with an obliterated AVM after treatment were subdivided according to treatment modality, there were no significant differences in their S-M groups compared with the control group. Similarly, those patients with nonobliterated AVMs analyzed according to their S-M grade showed a borderline significant difference, with S-M IV and V having a worse neuropsychological outcome compared with the other groups. Conclusions Patients harboring nonobliterated high-grade AVMs (S-M IV and V) scored worse than patients with nonobliterated AVM S-M grades I to III. This could be explained by the steal phenomenon. No differences in neuropsychological testing were found when comparing results according to nidus location. This study lends support to an active treatment policy for cerebral AVMs. Those patients in whom complete obliteration was achieved with treatment scored similarly to the background population, implying active AVM treatment does not cause deterioration in neuropsychological performance. This, together with a > 90% AVM obliteration rate, favors microsurgery as the treatment modality of choice whenever the AVM can be safely resected.

• MeSH
• dospělí MeSH
• intrakraniální arteriovenózní malformace komplikace   chirurgie   MeSH
• kognitivní poruchy diagnóza   etiologie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mikrochirurgie škodlivé účinky   MeSH
• mladý dospělý MeSH
• neuropsychologické testy * MeSH
• retrospektivní studie MeSH
• terapeutická embolizace škodlivé účinky   MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

Perinidální edém u arteriovenózních malformací (AVM) bývá spojován s předchozím krvácením. Zřídka jej nacházíme u neprasklých malformací, kde může být příčinou vzniku epileptických záchvatů či neurologického deficitu. V naší kazuistice prezentujeme případ pacienta s relativně malou arteriovenózní malformací v levém frontálním laloku obklopenou výrazným edémem mozku, u kterého došlo ke generalizovanému epileptickému záchvatu. Mozková angiografie a vyšetření magnetickou rezonancí ukázaly abnormitu odvodné drenážní žíly, což některými autory bývá považováno za etiologický faktor vzniku perinidálního edému u neprasklých AVM. Pacient podstoupil mikrochirurgickou totální resekci AVM s nekomplikovaným pooperačním průběhem.

Mass effect and collateral oedema in an arteriovenous malformation (AVM) are often seen to be associated with previous bleeding. Perilesional oedema can rarely occur in an unruptured AVM and cause clinical symptoms. We present a patient with relatively small left frontal AVM surrounded by substantial brain oedema in whom a generalized epileptic seizure occurred. Both – digital subtraction angiography (DSA) and MRI showed venous outflow abnormality, the most discussed aetiological factor of oedema in unruptured AVMs. The patient was successfully treated with microsurgical resection and made an uneventful recovery.

• MeSH
• edém mozku * etiologie   komplikace   MeSH
• intrakraniální arteriovenózní malformace * diagnostické zobrazování   chirurgie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• magnetická rezonanční tomografie MeSH
• mikrochirurgie MeSH
• mozkové žíly abnormality   MeSH
• neurochirurgické výkony MeSH
• pia mater krevní zásobení   MeSH
• počítačová rentgenová tomografie MeSH
• záchvaty etiologie   MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• Publikační typ
• kazuistiky MeSH