Long term neuroimaging and clinical outcome of brain Arteriovenous Malformations (bavm) treated with stereotactic radiosurgery (SRS).

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1 Long term neuroimaging and clinical outcome of brain Arteriovenous Malformations (bavm) treated with stereotactic radiosurgery (SRS). Poster No.: C-2489 Congress: ECR 2012 Type: Scientific Exhibit Authors: L. Guillen Vargas, F. Aparici-Robles, V. Moreno Ballester, V. Parkhutik, E. Mainar Tello, V. Vazquez Añon-Perez; Valencia/ES Keywords: Arteriovenous malformations, Treatment effects, Radiation effects, Contrast agent-intravenous, MR, Gamma knife, Catheter arteriography, Neuroradiology brain DOI: /ecr2012/C-2489 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Purpose Presenting long-term neuroradiological and clinical findings of a series of patients with brain Arterios Venous Malformation (bavms) treated with sterotactic radiosurgery (SRS). Page 2 of 23

3 Methods and Materials A consecutive series of patients with bavm treated with SRS between 1993 and 2009, and followed with intravenous contrast brain MRIs semesterly for the first 2-3 years and annually afterwards. Brain edema, blood-brain barrier breakdown and radionecrosis were defined as radiological endpoints and classified according to their intensity (mild, moderate or severe). Clinically, appearance or worsening of seizures or focal symptoms, development of headaches or signs endocranial hypertension, brain haemorrhage and AVM- related death were recorded by an independent neurologist. Page 3 of 23

4 Images for this section: Fig. 1: Axial FLAIR MR images demonstrating the classification of PRI. According to the extent of PRI change noted on the MR images, the PRI change was classified as no PRI change (A); mild (a narrow rim with high signal intensities surrounding the AVM, B); moderate (a lesion with high signal intensities surrounding the AVM and < one-fourth of the brain involved, C); and severe (a lesion with high signal intensities surrounding the AVM and > one-fourth of the brain involved, D). Ham et alj Neurosurg 109: , 2008 Ham et al. J Neurosurg 109: , 2008 Page 4 of 23

5 Results We reviewed 110 patients (52% male, mean age 38 years). Eleven cases were excluded due to incomplete records or loss of follow up. The rest was followed for a mean of 74 months, having received a median dose of 18 Gy prescribed to the 80% isodose. 39 % of patients had minimal o mild edema and 15% of patients developed moderate to severe lesions (AMV size and radiation dose being risk factors), most of the latter (71%) were symptomatic, being 5,5 times more likely to suffer seizures and 11 times more likely to develop focal symptoms or endocranial hypertension. These complications appeared a median of 23 months after the SRS. Brain haemorrhage was equally common in all patients, with annual bleeding rate of 2,7% during the first year, 0,9% until the 4th year and 0,4% afterwards.overall AVM-related mortality was 1,8%. Page 5 of 23

6 Images for this section: Fig. 1: Axial FLAIR MR images demonstrating the classification of PRI. According to the extent of PRI change noted on the MR images, the PRI change was classified as no PRI change (A); mild (a narrow rim with high signal intensities surrounding the AVM, B); moderate (a lesion with high signal intensities surrounding the AVM and < one-fourth of the brain involved, C); and severe (a lesion with high signal intensities surrounding the AVM and > one-fourth of the brain involved, D). Ham et alj Neurosurg 109: , 2008 Ham et al. J Neurosurg 109: , 2008 Page 6 of 23

7 Fig. 2: Case 1: Male, 35yo. Non-smoker. Seizures secondary to Frontal AVM. The AVM was treated with embolization and SRS (2005), Figures 2 and 3. In 2007 seizures increase in number and duration. MR showed a moderate oedema. (Figures 4 and 5). Treated with corticoids the patients improve. Page 7 of 23

8 Fig. 3: Case 1: Male, 35yo. Non-smoker. Seizures secondary to Frontal AVM. The AVM was treated with embolization and SRS (2005), Figures 2 and 3. In 2007 seizures increase in number and duration. MR showed a moderate oedema. (Figures 4 and 5). Treated with corticoids the patients improve. Page 8 of 23

9 Fig. 4: Case 1: Male, 35yo. Non-smoker. Seizures secondary to Frontal AVM. The AVM was treated with embolization and SRS (2005), Figures 2 and 3. In 2007 seizures increase in number and duration. MR showed a moderate oedema. (Figures 4 and 5). Treated with corticoids the patients improve. Page 9 of 23

10 Fig. 5: Case 1: Male, 35yo. Non-smoker. Seizures secondary to Frontal AVM. The AVM was treated with embolization and SRS (2005), Figures 2 and 3. In 2007 seizures increase in number and duration. MR showed a moderate oedema. (Figures 4 and 5). Treated with corticoids the patients improve. Page 10 of 23

11 Fig. 8: Case 2:Female 37 yo. Frontal AVM treated with multiple embolization and one sesión of SRS. MR 5 years after SRS showed severe edema (Figures 6 and 7) and radionecrosis (Figures 8 and 9). Page 11 of 23

12 Fig. 9: Case 2:Female 37 yo. Frontal AVM treated with multiple embolization and one sesión of SRS. MR 5 years after SRS showed severe edema (Figures 6 and 7) and radionecrosis (Figures 8 and 9). Page 12 of 23

13 Fig. 6: Case 2:Female 37 yo. Frontal AVM treated with multiple embolization and one sesión of SRS. MR 5 years after SRS showed severe edema (Figures 6 and 7) and radionecrosis (Figures 8 and 9). Page 13 of 23

14 Fig. 10: Case 3: Female, 34yo. Smoker. Talamic AVM treated with embolization (1993), SRS (1995 and 1999) Asymptomatic until march-08. Headache with vomiting. March FLAIR MR sequences showed an oedema (Figures 10 and 11) that increase in control RM 3 months after (Figures 12 and 13). Treated with corticoids she improved, but fat haemorrhage occurs on nov.08 (Figure 14). Page 14 of 23

15 Fig. 11: Case 3: Female, 34yo. Smoker. Talamic AVM treated with embolization (1993), SRS (1995 and 1999) Asymptomatic until march-08. Headache with vomiting. March FLAIR MR sequences showed an oedema (Figures 10 and 11) that increase in control RM 3 months after (Figures 12 and 13). Treated with corticoids she improved, but fat haemorrhage occurs on nov.08 (Figure 14). Page 15 of 23

16 Fig. 12: Case 3: Female, 34yo. Smoker. Talamic AVM treated with embolization (1993), SRS (1995 and 1999) Asymptomatic until march-08. Headache with vomiting. March FLAIR MR sequences showed an oedema (Figures 10 and 11) that increase in control RM 3 months after (Figures 12 and 13). Treated with corticoids she improved, but fat haemorrhage occurs on nov.08 (Figure 14). Page 16 of 23

17 Fig. 13: Case 3: Female, 34yo. Smoker. Talamic AVM treated with embolization (1993), SRS (1995 and 1999) Asymptomatic until march-08. Headache with vomiting. March FLAIR MR sequences showed an oedema (Figures 10 and 11) that increase in control RM 3 months after (Figures 12 and 13). Treated with corticoids she improved, but fat haemorrhage occurs on nov.08 (Figure 14). Page 17 of 23

18 Fig. 14: Case 3: Female, 34yo. Smoker. Talamic AVM treated with embolization (1993), SRS (1995 and 1999) Asymptomatic until march-08. Headache with vomiting. March FLAIR MR sequences showed an oedema (Figures 10 and 11) that increase in control RM 3 months after (Figures 12 and 13). Treated with corticoids she improved, but fat haemorrhage occurs on nov.08 (Figure 14).). Page 18 of 23

19 Fig. 7: Case 2:Female 37 yo. Frontal AVM treated with multiple embolization and one sesión of SRS. MR 5 years after SRS showed severe edema (Figures 6 and 7) and radionecrosis (Figures 8 and 9). Page 19 of 23

20 Conclusion Moderate to severe radiation-induced changes appear in 15% of patients, who usually become symptomatic years after treatment. More efforts are needed both to detect the neuroimaging findings and to determine the optimal clinical management, which remains unclear. Page 20 of 23

21 References Shin M, Maruyama K, Kurita H, et al. Analysis of nidus obliteration rates after gamma knife surgery for arteriovenous malformations based on long-term follow-up data: the University of Tokyo experience. J Neurosurg 2004; 101: Schneider BF, Eberhard DA, Steiner LE. Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 1997; 87: Huang PP, Kamiryo T, Nelson PK. De novo aneurysm formation after stereotactic radiosurgery of a residual arteriovenous malformation: case report. AJNR Am J Neuroradiol 2001; 22: Edmister WB, Lane JI, Gilbertson JR, Brown RD, Pollock BE. Tumefactive cysts: a delayed complication following radiosurgery for cerebral arterial venous malformations. AJNR Am J Neuroradiol 2005; 26: Oyoshi T, Hirahara K, Uetsuhara K, Yatsushiro K, Arita K. Delayed radiation necrosis 7 years after gamma knife surgery for arteriovenous malformation--two case reports. Neurol Med Chir (Tokyo) 2010; 50: Yamamoto M, Hara M, Ide M, Ono Y, Jimbo M, Saito I. Radiation-related adverse effects observed on neuro-imaging several years after radiosurgery for cerebral arteriovenous malformations. Surg Neurol 1998; 49: Izawa M, Hayashi M, Chernov M, et al. Long-term complications after gamma knife surgery for arteriovenous malformations. J Neurosurg 2005; 102 Suppl:34-7.: Chen HI, Burnett MG, Huse JT, Lustig RA, Bagley LJ, Zager EL. Recurrent late cerebral necrosis with aggressive characteristics after radiosurgical treatment of an arteriovenous malformation. Case report. J Neurosurg 2006; 105: Atkinson RP, Awad IA, Batjer HH, et al. Reporting terminology for brain arteriovenous malformation clinical and radiographic features for use in clinical trials. Stroke 2001; 32: Levegrun S, Hof H, Essig M, Schlegel W, Debus J. Radiation-induced changes of brain tissue after radiosurgery in patients with arteriovenous malformations: correlation with dose distribution parameters. Int J Radiat Oncol Biol Phys 2004; 59: Shin M, Kawahara N, Maruyama K, Tago M, Ueki K, Kirino T. Risk of hemorrhage from an arteriovenous malformation confirmed to have been obliterated on angiography after stereotactic radiosurgery. J Neurosurg 2005; 102: Page 21 of 23

22 12. Lindqvist M, Karlsson B, Guo WY, Kihlstrom L, Lippitz B, Yamamoto M. Angiographic long-term follow-up data for arteriovenous malformations previously proven to be obliterated after gamma knife radiosurgery. Neurosurgery 2000; 46: Prat R, Galeano I, Conde R, Simal JA, Cardenas E. Surgical removal after first bleeding of an arteriovenous malformation previously obliterated with radiosurgery: case report. Surg Neurol 2009; 71: Matsumoto H, Takeda T, Kohno K, et al. Delayed hemorrhage from completely obliterated arteriovenous malformation after gamma knife radiosurgery. Neurol Med Chir (Tokyo) 2006; 46: Bradac O, Mayeroa K, Hrabal P, Benes V. Haemorrhage from a radiosurgically treated arteriovenous malformation after its angiographically proven obliteration: a case report. Cen Eur Neurosurg 2010; 71:92-95 Page 22 of 23

23 Personal Information Page 23 of 23

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