Original Article
The Risk of Hemorrhage after Radiosurgery for Cerebral Arteriovenous Malformations
N Engl J Med 2005; 352:146-153January 13, 2005
- Abstract
Background
Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage is poorly understood.
Methods
We performed a retrospective observational study of 500 patients with malformations who were treated with radiosurgery with use of a gamma knife. The rates of hemorrhage were assessed during three periods: before radiosurgery, between radiosurgery and the angiographic documentation of obliteration of the malformation (latency period), and after angiographic obliteration.
Results
Forty-two hemorrhages were documented before radiosurgery (median follow-up, 0.4 year), 23 during the latency period (median follow-up, 2.0 years), and 6 after obliteration (median follow-up, 5.4 years). As compared with the period between diagnosis and radiosurgery, the risk of hemorrhage decreased by 54 percent during the latency period (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P<0.001). The risk was significantly reduced during the period after obliteration, as compared with the latency period (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). The reduction was greater among patients who presented with hemorrhage than among those without hemorrhage at presentation and similar in analyses that took into account the delay in confirming obliteration by means of angiography and analyses that excluded data obtained during the first year after diagnosis.
Conclusions
Radiosurgery significantly decreases the risk of hemorrhage in patients with cerebral arteriovenous malformations, even before there is angiographic evidence of obliteration. The risk of hemorrhage is further reduced, although not eliminated, after obliteration.
Media in This Article
Figure 1
Flow Diagram of the Study Population.Table 1
Characteristics of 500 Patients Treated with Radiosurgery.Article Activity
- Article
During the past two decades, stereotactic radiosurgery has been widely used to treat cerebral arteriovenous malformations,1-7 providing angiographic evidence of cure (obliteration of the malformation) in 80 to 95 percent of patients after a latency period of three to five years.2,8-11 Hemorrhage has been reported to occur in 2 to 5 percent of patients per year between the time of radiosurgery and angiographic obliteration of the malformation; however, it has been unclear whether — and to what extent — the risk is reduced during this period as compared with the risk before radiosurgery.4,12-19 The extent to which the risk of hemorrhage is further reduced after angiographic obliteration is also unclear. To address these questions, we performed a retrospective study involving 500 patients who were treated with stereotactic radiosurgery at our institute.
Methods
Patients
Between July 1990 and June 2003, 531 consecutive patients with angiographically visible cerebral arteriovenous malformations underwent stereotactic radiosurgery at our institute. Our institutional review board did not require informed consent for study participation because the study relied on information obtained as part of routine clinical care.
The selection criterion for radiosurgery was, in principle, the finding of small malformations (less than 3 cm) in critical, or eloquent, areas of the brain (including the sensorimotor, language, or visual cortex; the hypothalamus or thalamus; the internal capsule; the brain stem; the cerebellar peduncles; and the deep cerebellar nuclei) that, if injured, result in disabling neurologic deficits.20 Surgical resection, rather than radiosurgery, was generally recommended for other types of malformation considered to be amenable to a surgical approach, although some patients chose radiosurgery because of its noninvasive nature. Radiosurgery was recommended for patients with coexisting conditions, such as chronic renal failure necessitating hemodialysis or respiratory dysfunction, who were considered at high risk for complications if they underwent direct surgery under general anesthesia. If a patient was considered a suitable candidate for radiosurgery, the procedure was performed within three months after evaluation at our center. In 10 patients with an aneurysm associated with the malformation, management involved clipping in 2 patients, 1 of whom later underwent embolization of the malformation; wrapping in 1 patient, who later underwent embolization of the malformation; embolization alone in 1 patient; and observation in 6 patients. The treatments in these 10 patients did not change the angiographic appearance of the malformations.
Radiosurgery Technique
Stereotactic radiosurgery was performed with the patient under local anesthesia, which was supplemented with intravenous sedation when necessary, in a single session with the use of a gamma knife (Elekta Instruments), which irradiated the malformation defined by imaging. Radiosurgery was guided by angiography alone until February 1992; thereafter, computed tomography (CT) or magnetic resonance imaging (MRI) was included. Image-integrated treatment planning was performed jointly by neurosurgeons and radiation oncologists with the aid of commercially available software (KULA or Leksell GammaPlan, Elekta Instruments). During radiosurgery, the patients lay on a gamma-knife couch and were attached to a gamma-knife collimator helmet with a stereotactic frame. In principle, the dose applied to the margin of each malformation was designed to be at least 20 Gy with the use of 50 percent isodose lines; however, doses were occasionally reduced, depending on the volume and location of malformations or the patient's status.
Follow-up Evaluations
Patients were evaluated clinically every six months after radiosurgery. Whenever patients had any acute deterioration in their neurologic condition, they were asked to come to our institute or to see their referring physicians, who, in turn, provided us with the appropriate information. Hemorrhage was defined as a clinically symptomatic event (sudden onset of headache, seizure, focal deficits, death, or a combination of these) along with signs of fresh bleeding from the previously diagnosed arteriovenous malformations, detected by means of CT or MRI.21 Every year after radiosurgery until the end of 1992, patients underwent serial cerebral angiography; less invasive imaging techniques, such as MRI or CT, were used every six months thereafter. Angiography was generally delayed until obliteration was suggested by these studies.22 Angiographic obliteration was defined as the absence of abnormal vessels in the former nidus of the malformation, the disappearance or normalization of draining veins from the area, and a normal circulation time on angiography.23 The determination that obliteration of the malformation had occurred was made independently by both neurosurgeons and neuroradiologists who were aware of the patients' histories.
Clinical follow-up was continued even after obliteration in the majority of patients, and if malformations were not occluded, patients were asked to undergo angiography again 6 to 12 months later. A second radiosurgical treatment was generally recommended if obliteration was not observed by three years after the initial treatment.
Information on all patients was prospectively entered into a computer database at the time of their treatment and at each clinical follow-up visit. The dates of diagnosis, radiosurgical treatment, previous or additional hemorrhage, angiographic obliteration, and the last follow-up visit were included in the analyses, along with data on the initial clinical presentation and treatment history. The observation period was divided into the following three intervals: before radiosurgery, the interval from diagnosis to radiosurgery; the latency period, the interval from radiosurgery to angiographic obliteration; and after obliteration, the interval from angiographic obliteration to the end of the follow-up period (Figure 1Figure 1
Flow Diagram of the Study Population.).Statistical Analysis
We used a time-dependent Cox proportional-hazards model to analyze the effect of radiosurgery on the incidence of intracranial hemorrhage, with use of SPSS software, version 11.24,25 We defined two sets of trinary time-dependent covariates — for example, as –1 for the period before radiosurgery, as 0 for the latency period, and as 1 for the period after obliteration. The primary end point was the first hemorrhage after the date of diagnosis. For patients who had received other treatments before radiosurgery, the last date of the previous treatment was substituted for the time of diagnosis in an attempt to eliminate any effects of this therapy. Data on patients who underwent a second radiosurgical treatment were censored at that time. Data on patients who declined to undergo angiography to confirm obliteration were censored on the date of the first less invasive imaging study that suggested obliteration. In the overall analysis, the patients were also divided into two groups: those initially presenting with hemorrhage and those without hemorrhage at presentation.
Next, we included hemorrhage as an initial clinical presentation in the analysis as a fixed covariate. Finally, we added six conditions (three intervals each among patients presenting with hemorrhage and those presenting without hemorrhage) in defining time-dependent covariates. To compare the results of these two models, we used the likelihood-ratio test to detect interaction terms between presentation with or without hemorrhage and trinary time-dependent covariates.
To adjust for potential biases, we performed four additional analyses as follows. First, for patients who had received previous treatment, we reanalyzed the data including the period between diagnosis and previous treatment in the period before radiosurgery. Second, because the exact date of obliteration was unclear (since obliteration was identified only after the fact, at the time of angiography), we performed a secondary analysis assuming that obliteration occurred six months before it was confirmed by angiography, as previously described.15 Third, because the rate of repeated hemorrhages from ruptured arteriovenous malformations is reported to be highest in the first year and to decline rapidly thereafter,26-28 we reanalyzed the data excluding the data from the first year after diagnosis. Fourth, because we could not eliminate the possibility that hemorrhage occurred in patients for whom no information was available after radiosurgery, we performed an analysis including all 531 patients and assuming that all patients without any information had hemorrhages three months after radiosurgery (within the recommended six-month follow-up interval) and that in patients whose neurologic state was stable, malformations were obliterated at three years (when most malformations are expected to have been obliterated).
The reduction in the incidence of hemorrhage in the periods after radiosurgery was calculated as 100 × (1 – hazard ratio). A two-sided P value of less than 0.05 was considered to indicate statistical significance. The annual hemorrhage rate was calculated as the number of hemorrhages divided by the sum of the observation periods. The cumulative rate of obliteration was calculated according to the Kaplan–Meier method.29
Results
Of the 531 patients, 31 were unable to return for serial follow-up after radiosurgery for personal reasons and were excluded from the analyses: 2 of these patients had a hemorrhage before radiosurgery, 17 were confirmed not to have had a clinically significant hemorrhage through subsequent communication by telephone or mail, and no information was available for the remaining 12 patients, 3 of whom lived overseas. Therefore, the final study group contained 500 patients. Their baseline characteristics are summarized in Table 1Table 1
Characteristics of 500 Patients Treated with Radiosurgery..The diagnosis was based on the initial clinical presentation in 441 patients and was incidental in 59 patients, who underwent imaging for other reasons. Partial resection, several sessions of endovascular embolization, or both, had been performed before radiosurgery in 62, 65, and 10 patients, respectively. Radiation doses were less than 20 Gy in 35 patients. The median observation period was 7.8 years (Table 1). For most patients who had a long delay between diagnosis and radiosurgery, the interval reflected the time between diagnosis and referral to our institute. The cumulative rates of obliteration were 81 percent at four years and 91 percent at six years. Transient radiation-induced neurologic deterioration was noted in 26 patients (5.2 percent) between 1 and 34 months (median, 7) after radiosurgery (dysesthesia in 11 patients, hemiparesis in 9, aphasia in 1, and cranial-nerve deficits in 5). Seven patients (1.4 percent) had persistent neurologic deterioration (three had dysesthesia, two had hemiparesis, one had aphasia, and one had cranial-nerve deficits).
Hemorrhage occurred before radiosurgery in 42 of 500 patients (median follow-up, 0.4 year), during the latency period in 23 of 458 patients (median follow-up, 2.0 years), and after obliteration in 6 of 250 patients (median follow-up, 5.4 years) (Figure 1). Repeated angiography in the six patients who had a hemorrhage after obliteration revealed no recanalization of the original malformations; we previously reported on the clinical course and imaging studies of one of these patients.8 Of 29 hemorrhages observed during the latency period or after obliteration, 19 were directly confirmed at our institute (12 immediately after clinical presentation and 7 after diagnosis by referring physicians). Seven patients died suddenly from hemorrhages, and we reviewed the radiologic studies provided by the referring physicians. In the case of three patients, the diagnosis of hemorrhage was made by the referring physicians, but radiologic test results were not provided.
Of the 429 patients without additional hemorrhages, 319 reached the latest cutoff of our data set. Reasons for censoring data on patients without complete follow-up included loss to follow-up (63 patients), refusal to undergo angiography to confirm obliteration (25 patients), a second radiosurgical treatment (16 patients), and death from unrelated causes (lung cancer in 2 and gastric cancer, pneumonia, suicide, and ileus in 1 patient each).
As compared with the overall risk of hemorrhage before radiosurgery, the risk was reduced by 54 percent during the latency period after radiosurgery (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P<0.001) (Table 2Table 2
Risk of Hemorrhage from Arteriovenous Malformations According to the Observation Period.). As compared with the risk of hemorrhage during the latency period, the risk was reduced by 74 percent after obliteration (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). For each comparison, the decrease in risk was greater among the 310 patients who presented with hemorrhage than among the 190 without hemorrhage at presentation. Although the risk of hemorrhage among the 190 patients without hemorrhage at presentation also tended to decrease during the latency period and after obliteration, the difference from the value before radiosurgery was not significant. The reduction in risk was similar in analyses that included presentation with or without hemorrhage as a fixed covariate (Table 2). There was a significant interaction between the period relative to radiosurgery and whether or not a patient presented with hemorrhage (P=0.045).Similar results were obtained in analyses that included the period between diagnosis and prior therapy in the interval before radiosurgery and in analyses that considered the time of obliteration to be six months before angiographic confirmation. The results were also materially unchanged by the exclusion of data obtained during the first year after diagnosis and the inclusion of all 531 patients in the analysis (Table 2).
Among the patients presenting with hemorrhage, the annual rates of subsequent hemorrhage in the period before radiosurgery appeared similar over a period of three or more years. However, the numbers of events were small (Table 3Table 3
Annual Rate of Repeated Hemorrhage before Radiosurgery among 310 Patients Presenting with Hemorrhage.).Discussion
We found that the risk of hemorrhage from cerebral arteriovenous malformations was significantly decreased after radiosurgery, both during the latency period (between radiosurgery and angiographic obliteration) and after angiographic obliteration. Previous studies have reported that the risk of hemorrhage during the latency period decreases,13,14 remains unchanged,15,16 or even increases,4,17 as compared with the natural course of the disease. These studies tended to compare the risk of hemorrhage among selected patients who underwent radiosurgery with patients who did not undergo radiosurgery, whereas we analyzed changes in the rate of hemorrhage relative to the timing of radiosurgery in a large cohort of consecutive patients.
Most previous studies assumed that angiographic obliteration was the ultimate goal of radiosurgery,3,5,6,23 because hemorrhage was rare once obliteration was confirmed.30 Although recanalization of malformations can lead to hemorrhages after obliteration,31,32 this phenomenon was not observed in the six patients who had hemorrhage after obliteration in our study. We found that a small risk of hemorrhage remained after obliteration, although it was markedly lower than that before radiosurgery.
We did not address the mechanisms by which the risk of hemorrhage may be reduced. However, histopathological studies of arteriovenous malformations after radiosurgery suggest potential mechanisms. Progressive thickening of the intimal layer,33 which begins as early as three months after radiosurgery,34 appears to decrease the stress to the vessel walls.13 In addition, partial or complete thrombosis of the irradiated vessels may decrease the number of patent vessels in the malformation.35 In vessels with a decreased diameter, thickening of the endothelium may cause occlusion at a relatively early stage. When blood flow declines below the threshold of detection by angiography, malformations, in effect, become invisible (angiographic obliteration), although they may still be evident histologically.30
Our study has some limitations. Because we did not include a control group of patients who did not undergo radiosurgery, one concern is whether the decrease in the risk of hemorrhage after radiosurgery reflects, at least in part, the natural history of malformations, rather than effects of the procedure itself. A natural decline in the rate of recurrent bleeding has been reported within one year after the rupture of arteriovenous malformations.21,26-28 Because the criteria for conservative management were not well described in previous reports of the natural history of ruptured malformations,26-28 it has remained unclear whether small malformations that can be effectively treated with radiosurgery have a similar natural decline in the rate of repeated hemorrhage. However, the Cox models we used accounted for the time since diagnosis. In addition, hemorrhage rates before radiosurgery in our cohort appeared stable over a period of more than three years after diagnosis, although the number of patients observed for longer periods before radiosurgery was limited. In addition, our results did not materially change in an analysis that excluded data obtained during the first year after diagnosis.
Another potential problem is the delay in confirming angiographic obliteration.15,16 The exact time of obliteration was not known but, instead, was inferred on the basis of findings on consecutive imaging studies. Angiography was initially carried out at six-month intervals; after 1993, less invasive imaging was performed every six months.22 However, our results were materially unchanged after adjustment for a potential delay of six months in identifying obliteration. Although some patients had prior treatments, these treatments are not expected to have a delayed effect, and the results were more conservative when the period before these treatments was excluded. Because our clinical practice incorporates close follow-up of our patients according to standard schedules, the retrospective nature of our analysis should not pose a problem. The lack of blinding among those reviewing studies and judging outcomes is also acceptable, since obliteration and hemorrhage were diagnosed separately. There was some loss to follow-up, but the assignment of extreme outcomes to these patients also did not substantively affect the results of the analyses.
The gold standard for evaluating the effect of radiosurgery on the risk of hemorrhage would be a randomized trial comparing a group undergoing radiosurgery with a group receiving no treatment. However, this approach is not possible, because the beneficial effects of radiosurgery in terms of angiographic cure are well recognized and hemorrhage is rare after complete obliteration.3,7-9 The large size and close follow-up of our cohort made it well suited to an assessment of the outcomes of radiosurgery.
In conclusion, we found that the risk of hemorrhage from cerebral arteriovenous malformations was significantly reduced after stereotactic radiosurgery during the latency period (after radiosurgery and before angiographic obliteration) and that it was reduced even further after obliteration. However, a risk of hemorrhage remained even after malformations were no longer visible on imaging studies.
Source Information
From the Departments of Neurosurgery (K.M., N.K., M.S., H.K., S.K., A.M., T.K.), Radiology (M.T.), and Clinical Bioinformatics (J.K.), University of Tokyo Hospital, Tokyo.
Address reprint requests to Dr. Maruyama at the Department of Neurosurgery, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan, or at kskmaru-tky@umin.ac.jp.
- References
References
1
The Arteriovenous Malformation Study Group
Full Text | Web of Science | Medline2
Fleetwood IG ,Steinberg GK . Arteriovenous malformations. Lancet 2002;359:863-873
CrossRef | Web of Science | Medline3
Ogilvy CS ,Stieg PE ,Awad I , et al. AHA scientific statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 2001;32:1458-1471
CrossRef | Web of Science | Medline4
Steinberg GK ,Fabrikant JI ,Marks MP , et al. Stereotactic heavy-charged-particle Bragg-peak radiation for intracranial arteriovenous malformations. N Engl J Med 1990;323:96-101
Full Text | Web of Science | Medline5
Lunsford LD ,Kondziolka D ,Flickinger JC , et al. Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 1991;75:512-524
CrossRef | Web of Science | Medline6
Steiner L ,Lindquist C ,Adler JR ,Torner JC ,Alves W ,Steiner M . Clinical outcome of radiosurgery for cerebral arteriovenous malformations. J Neurosurg 1992;77:1-8
CrossRef | Web of Science | Medline7
Maruyama K ,Kondziolka D ,Niranjan A ,Flickinger JC ,Lunsford LD . Stereotactic radiosurgery for brainstem arteriovenous malformations: factors affecting outcome. J Neurosurg 2004;100:407-413
CrossRef | Web of Science | Medline8
Shin M ,Kawamoto S ,Kurita H , et al. Retrospective analysis of a 10-year experience of stereotactic radiosurgery for arteriovenous malformations in children and adolescents. J Neurosurg 2002;97:779-784
CrossRef | Web of Science | Medline9
Karlsson B ,Lindquist C ,Steiner L . Prediction of obliteration after gamma knife surgery for cerebral arteriovenous malformations. Neurosurgery 1997;40:425-431
CrossRef | Web of Science | Medline10
Colombo F ,Pozza F ,Chierego G ,Casentini L ,De Luca G ,Francescon P . Linear accelerator radiosurgery of cerebral arteriovenous malformations: an update. Neurosurgery 1994;34:14-21
CrossRef | Web of Science | Medline11
Friedman WA ,Bova FJ ,Mendenhall WM . Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome. J Neurosurg 1995;82:180-189
CrossRef | Web of Science | Medline12
Karlsson B ,Lax I ,Soderman M . Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 2001;49:1045-1051
CrossRef | Web of Science | Medline13
Karlsson B ,Lindquist C ,Steiner L . Effect of gamma knife surgery on the risk of rupture prior to AVM obliteration. Minim Invasive Neurosurg 1996;39:21-27
CrossRef | Web of Science | Medline14
Levy RP ,Fabrikant JI ,Frankel KA ,Phillips MH ,Lyman JT . Stereotactic heavy-charged-particle Bragg peak radiosurgery for the treatment of intracranial arteriovenous malformations in childhood and adolescence. Neurosurgery 1989;24:841-852
CrossRef | Web of Science | Medline15
Pollock BE ,Flickinger JC ,Lunsford LD ,Bissonette DJ ,Kondziolka D . Hemorrhage risk after stereotactic radiosurgery of cerebral arteriovenous malformations. Neurosurgery 1996;38:652-661
CrossRef | Web of Science | Medline16
Friedman WA ,Blatt DL ,Bova FJ ,Buatti JM ,Mendenhall WM ,Kubilis PS . The risk of hemorrhage after radiosurgery for arteriovenous malformations. J Neurosurg 1996;84:912-919
CrossRef | Web of Science | Medline17
Fabrikant JI ,Levy RP ,Steinberg GK , et al. Charged-particle radiosurgery for intracranial vascular malformations. Neurosurg Clin N Am 1992;3:99-139
Medline18
Ondra SL ,Troupp H ,George ED ,Schwab K . The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 1990;73:387-391
CrossRef | Web of Science | Medline19
Crawford PM ,West CR ,Chadwick DW ,Shaw MD . Arteriovenous malformations of the brain: natural history in unoperated patients. J Neurol Neurosurg Psychiatry 1986;49:1-10
CrossRef | Web of Science | Medline20
Spetzler RF ,Martin NA . A proposed grading system for arteriovenous malformations. J Neurosurg 1986;65:476-483
CrossRef | Web of Science | Medline21
Mast H ,Young WL ,Koennecke HC , et al. Risk of spontaneous haemorrhage after diagnosis of cerebral arteriovenous malformation. Lancet 1997;350:1065-1068
CrossRef | Web of Science | Medline22
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;101:18-24
CrossRef | Web of Science | Medline23
Lindquist C, Steiner L. Stereotactic radiosurgical treatment of arteriovenous malformations. In: Lunsford LD, ed. Modern stereotactic neurosurgery. Boston: Martinus Nijhoff Publishing, 1988:491-505.
24
Crowley J ,Hu M . Covariance analysis of heart-transplant survival data. J Am Stat Assoc 1977;72:27-36
CrossRef | Web of Science25
Cox DR . Regression models and life-tables. J R Stat Soc [B] 1972;34:187-22026
Graf CJ ,Perret GE ,Torner JC . Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 1983;58:331-337
CrossRef | Web of Science | Medline27
Itoyama Y ,Uemura S ,Ushio Y , et al. Natural course of unoperated intracranial arteriovenous malformations: study of 50 cases. J Neurosurg 1989;71:805-809
CrossRef | Web of Science | Medline28
Fults D ,Kelly DL Jr . Natural history of arteriovenous malformations of the brain: a clinical study. Neurosurgery 1984;15:658-662
CrossRef | Web of Science | Medline29
Kaplan EL ,Meier P . Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481
CrossRef | Web of Science30
Yamamoto M ,Jimbo M ,Kobayashi M , et al. Long-term results of radiosurgery for arteriovenous malformation: neurodiagnostic imaging and histological studies of angiographically confirmed nidus obliteration. Surg Neurol 1992;37:219-230
CrossRef | Web of Science | Medline31
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;46:803-810
CrossRef | Web of Science | Medline32
Szeifert GT ,Salmon I ,Baleriaux D ,Brotchi J ,Levivier M . Immunohistochemical analysis of a cerebral arteriovenous malformation obliterated by radiosurgery and presenting with re-bleeding: case report. Neurol Res 2003;25:718-721
CrossRef | Web of Science | Medline33
Schneider BF ,Eberhard DA ,Steiner LE . Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 1997;87:352-357
CrossRef | Web of Science | Medline34
Phillips T. Early and late effects of radiation on normal tissues. In: Gutin P, Leibel S, Sheline G, eds. Radiation injury to the nervous system. New York: Raven Press, 1991:37-55.
35
Chang SD ,Shuster DL ,Steinberg GK ,Levy RP ,Frankel K . Stereotactic radiosurgery of arteriovenous malformations: pathologic changes in resected tissue. Clin Neuropathol 1997;16:111-116
Web of Science | Medline
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Tomoyuki Koga, Keisuke Maruyama, Kyousuke Kamada, Takahiro Ota, Masahiro Shin, Daisuke Itoh, Naoto Kunii, Kenji Ino, Atsuro Terahara, Shigeki Aoki. (2011) Outcomes of Diffusion Tensor Tractography–Integrated Stereotactic Radiosurgery. International Journal of Radiation OncologyBiologyPhysics
CrossRef18
Motoaki FUJIMOTO, Junji UNO, Yoshiaki IKAI, Satoshi INOHA, Yasutoshi KAI, Kazushi MAEDA, Shintaro NAGAOKA, So TOKUNAGA, Hidefuku GI. (2011) Risk of Rebleeding in Arteriovenous Malformations Due to Impaired Venous Drainage After Radiosurgery. Neurologia medico-chirurgica 51:8, 585-587
CrossRef19
Takashi Shuto, Shigeo Matsunaga, Jun Suenaga. (2011) Surgical Treatment for Late Complications following Gamma Knife Surgery for Arteriovenous Malformations. Stereotactic and Functional Neurosurgery 89:2, 96-102
CrossRef20
William A. Friedman, Frank J. Bova. 2011. Radiosurgery for Arteriovenous Malformations. , 1374-1387.
CrossRef21
Douglas Kondziolka, Hideyuki Kano, Huai-che Yang, John C. Flickinger, L. Lunsford. (2010) Radiosurgical management of pediatric arteriovenous malformations. Child's Nervous System 26:10, 1359-1366
CrossRef22
Tomoyuki Koga, Masahiro Shin, Keisuke Maruyama, Atsuro Terahara, Nobuhito Saito. (2010) Long-term Outcomes of Stereotactic Radiosurgery for Arteriovenous Malformations in the Thalamus. Neurosurgery 67:2, 398-403
CrossRef23
Chun-Po Yen, Surbhi Jain, Iftikhar-ul Haq, Jay Jagannathan, David Schlesinger, Jason Sheehan, Ladislau Steiner. (2010) Repeat Gamma Knife Surgery for Incompletely Obliterated Cerebral Arteriovenous Malformations. Neurosurgery 67:1, 55-64
CrossRef24
Dennis R. Buis, Otto W.M. Meijer, René van den Berg, Frank J. Lagerwaard, Joost C.J. Bot, Ben J. Slotman, W. Peter Vandertop. (2010) Clinical outcome after repeated radiosurgery for brain arteriovenous malformations. Radiotherapy and Oncology 95:2, 250-256
CrossRef25
Joshua D. Lawson, Jia-Zhu Wang, Sameer K. Nath, Roger Rice, Todd Pawlicki, Arno J. Mundt, Kevin Murphy. (2010) Intracranial application of IMRT based radiosurgery to treat multiple or large irregular lesions and verification of infra-red frameless localization system. Journal of Neuro-Oncology 97:1, 59-66
CrossRef26
Jian Tu, Athula Karunanayaka, Apsara Windsor, Marcus A. Stoodley. (2010) Comparison of an animal model of arteriovenous malformation with human arteriovenous malformation. Journal of Clinical Neuroscience 17:1, 96-102
CrossRef27
Tomoyuki KOGA, Masahiro SHIN, Nobuhito SAITO. (2010) Role of Gamma Knife Radiosurgery in Neurosurgery: Past and Future Perspectives. Neurologia medico-chirurgica 50:9, 737-748
CrossRef28
Takashi SHUTO, Shigeo MATSUNAGA, Jun SUENAGA, Shigeo INOMORI, Hideyo FUJINO. (2010) Cyst Formation Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation. Surgery for Cerebral Stroke 38:4, 228-234
CrossRef29
Yusuke MORIHIRO, Kei HARADA, Shoichi KATO, Hideyuki ISHIHARA, Satoshi SHIRAO, Hisato NAKAYAMA, Tatsuo AKIMURA, Michiyasu SUZUKI. (2010) Delayed Parenchymal Hemorrhage Following Successful Embolization of Brainstem Arteriovenous Malformation. Neurologia medico-chirurgica 50:8, 661-664
CrossRef30
Zuair Abu-Salma, François Nataf, May Ghossoub, Michel Schlienger, Jean-François Meder, Emmanuel Houdart, François-Xavier Roux. (2009) THE PROTECTIVE STATUS OF SUBTOTAL OBLITERATION OF ARTERIOVENOUS MALFORMATIONS AFTER RADIOSURGERY. Neurosurgery 65:4, 709-718
CrossRef31
Dorothea Strozyk, Raul G. Nogueira, Sean D. Lavine. (2009) Endovascular Treatment of Intracranial Arteriovenous Malformation. Neurosurgery Clinics of North America 20:4, 399-418
CrossRef32
Keisuke Maruyama, Tomoyuki Koga, Kyousuke Kamada, Takahiro Ota, Daisuke Itoh, Kenji Ino, Hiroshi Igaki, Shigeki Aoki, Yoshitaka Masutani, Masahiro Shin, Nobuhito Saito. (2009) Arcuate fasciculus tractography integrated into Gamma Knife surgery. Journal of Neurosurgery 111:3, 520-526
CrossRef33
Brian J. Williams, Dima Suki, Benjamin D. Fox, Christopher E. Pelloski, Marcos V. C. Maldaun, Raymond E. Sawaya, Frederick F. Lang, Ganesh Rao. (2009) Stereotactic radiosurgery for metastatic brain tumors: a comprehensive review of complications. Journal of Neurosurgery 111:3, 439-448
CrossRef34
Juanita M. Celix, James G. Douglas, David Haynor, Robert Goodkin. (2009) Thrombosis and hemorrhage in the acute period following Gamma Knife surgery for arteriovenous malformation. Journal of Neurosurgery 111:1, 124-131
CrossRef35
J. Tu, M.A. Stoodley, M.K. Morgan, K.P. Storer, R. Smee. (2009) Different responses of cavernous malformations and arteriovenous malformations to radiosurgery. Journal of Clinical Neuroscience 16:7, 945-949
CrossRef36
Manish Kumar Kasliwal, Shashank Sharad Kale, Aditya Gupta, Narayanam Anantha Sai Kiran, Manish Singh Sharma, Bhawani Shanker Sharma, Ashok K. Mahapatra. (2009) Outcome after hemorrhage following Gamma Knife surgery for cerebral arteriovenous malformations. Journal of Neurosurgery 110:5, 1003-1009
CrossRef37
Kanako Kunishima, Harushi Mori, Daisuke Itoh, Shigeki Aoki, Hiroyuki Kabasawa, Tomoyuki Koga, Keisuke Maruyama, Tomohiko Masumoto, Osamu Abe, Kuni Ohtomo. (2009) Assessment of arteriovenous malformations with 3-Tesla time-resolved, contrast-enhanced, three-dimensional magnetic resonance angiography. Journal of Neurosurgery 110:3, 492-499
CrossRef38
Joshua D. Lawson, Tim Fox, Anthony F. Waller, Lawrence Davis, Ian Crocker. (2009) Multileaf Collimator-Based Linear Accelerator Radiosurgery: Five-Year Efficiency Analysis. Journal of the American College of Radiology 6:3, 190-193
CrossRef39
Seung-Yeob Yang, Dong Gyu Kim, Hyun-Tai Chung, Sun Ha Paek, Jae Hyo Park, Dae Hee Han. (2009) Radiosurgery for large cerebral arteriovenous malformations. Acta Neurochirurgica 151:2, 113-124
CrossRef40
Rene O. Sanchez-Mejia, Michael W. McDermott, Jeffery Tan, Helen Kim, William L. Young, Michael T. Lawton. (2009) RADIOSURGERY FACILITATES RESECTION OF BRAIN ARTERIOVENOUS MALFORMATIONS AND REDUCES SURGICAL MORBIDITY. Neurosurgery 64:2, 231-240
CrossRef41
Kyoung Eun Lee, Choong Gon Choi, Jin Woo Choi, Byung Se Choi, Deok Hee Lee, Sang Joon Kim, Do Hoon Kwon. (2009) Detection of Residual Brain Arteriovenous Malformations after Radiosurgery: Diagnostic Accuracy of Contrast-Enhanced Three-Dimensional Time of Flight MR Angiography at 3.0 Tesla. Korean Journal of Radiology 10:4, 333
CrossRef42
Lori C. Jordan. (2008) Assessment and treatment of stroke in children. Current Treatment Options in Neurology 10:6, 399-409
CrossRef43
Lucien A. Nedzi. (2008) The Implementation of Ablative Hypofractionated Radiotherapy for Stereotactic Treatments in the Brain and Body: Observations on Efficacy and Toxicity in Clinical Practice. Seminars in Radiation Oncology 18:4, 265-272
CrossRef44
Manish Kumar Kasliwal, Shashank Sharad Kale, Aditya Gupta, Narayanam Anantha Sai Kiran, Manish Singh Sharma, Deepak Agrawal, Bhawani Shanker Sharma, Ashok K. Mahapatra. (2008) Does hemorrhagic presentation in cerebral arteriovenous malformations affect obliteration rate after gamma knife radiosurgery?. Clinical Neurology and Neurosurgery 110:8, 804-809
CrossRef45
Pantaleo Romanelli, John R Adler. (2008) Technology Insight: image-guided robotic radiosurgery—a new approach for noninvasive ablation of spinal lesions. Nature Clinical Practice Oncology 5:7, 405-414
CrossRef46
Gang Zhao, Jun-chao Liang, Wei-min Wang, Hong-xun Wu, Lin Li, Zi-heng Qin, Yu-hao Zhang. (2008) Long-term Effects of Gamma-knife Radiosurgery for Cerebral Arteriovenous Malformation. Neurosurgery Quarterly 18:2, 126-129
CrossRef47
Dieter Schmidt, Mona Pache, Martin Schumacher. (2008) The Congenital Unilateral Retinocephalic Vascular Malformation Syndrome (Bonnet-Dechaume-Blanc Syndrome or Wyburn-Mason Syndrome): Review of the Literature. Survey of Ophthalmology 53:3, 227-249
CrossRef48
D. R. Buis, C. M. F. Dirven, F. J. Lagerwaard, E. S. Mandl, G. J. Lycklama á Nijeholt, D. S. Eshghi, R. Berg, J. C. Baayen, O. W. M. Meijer, B. J. Slotman, W. P. Vandertop. (2008) Radiosurgery of brain arteriovenous malformations in children. Journal of Neurology 255:4, 551-560
CrossRef49
Keisuke Maruyama, Kyousuke Kamada, Takahiro Ota, Tomoyuki Koga, Daisuke Itoh, Kenji Ino, Shigeki Aoki, Masao Tago, Yoshitaka Masutani, Masahiro Shin, Nobuhito Saito. (2008) Tolerance of Pyramidal Tract to Gamma Knife Radiosurgery Based on Diffusion-Tensor Tractography. International Journal of Radiation Oncology*Biology*Physics 70:5, 1330-1335
CrossRef50
Douglas Kondziolka, L. Dade Lunsford, John C. Flickinger. (2008) THE APPLICATION OF STEREOTACTIC RADIOSURGERY TO DISORDERS OF THE BRAIN. Neurosurgery 62:Supplement 2, SHC-707???SHC-720
CrossRef51
Seung-Yeob Yang, Dong Gyu Kim, Hyun-Tai Chung. (2008) Radiosurgery for Intracranial Disorders. Journal of the Korean Medical Association 51:1, 27
CrossRef52
Jae-Gyun Choe, Yong-Seok Im, Jong-Soo Kim, Seung-Chyul Hong, Hyung-Jin Shin, Jung-Il Lee. (2008) Retrospective Analysis on 76 Cases of Cerebral Arteriovenous Malformations Treated by Gamma Knife Radiosurgery. Journal of Korean Neurosurgical Society 43:6, 265
CrossRef53
Hisashi NAGASHIMA, Kazuhiro HONGO, Toshiki TAKEMAE, Fusakazu OYA, Jun-ichi KOYAMA, Tetsuya GOTO, Shigeaki KOBAYASHI. (2008) Surgical Treatment for High-grade Arteriovenous Malformation: Efficacy of Microsurgical Resection Utilizing Preoperative Embolization and Intraoperative Monitoring. Surgery for Cerebral Stroke 36:1, 24-28
CrossRef54
Keisuke MARUYAMA. (2008) Role of Radiosurgery in the Management of High Grade AVMs. Surgery for Cerebral Stroke 36:1, 19-23
CrossRef55
Robert M. Starke, Ricardo J. Komotar, Brian Y. Hwang, Laura E. Fischer, Marc L. Otten, Maxwell B. Merkow, Matthew C. Garrett, Steven R. Isaacson, E. Sander Connolly Jr.. (2008) A Comprehensive Review of Radiosurgery for Cerebral Arteriovenous Malformations: Outcomes, Predictive Factors, and Grading Scales. Stereotactic and Functional Neurosurgery 86:3, 191-199
CrossRef56
Shigeki Yamada, Yasushi Takagi, Kazuhiko Nozaki, Ken-ichiro Kikuta, Nobuo Hashimoto. (2007) Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations. Journal of Neurosurgery 107:5, 965-972
CrossRef57
Keisuke Maruyama, Kyousuke Kamada, Masahiro Shin, Daisuke Itoh, Yoshitaka Masutani, Kenji Ino, Masao Tago, Nobuhito Saito. (2007) Optic radiation tractography integrated into simulated treatment planning for Gamma Knife surgery. Journal of Neurosurgery 107:4, 721-726
CrossRef58
Brenda Clark, Michael McKenzie, James Robar, Emily Vollans, Charlie Candish, Brian Toyota, Andrew Lee, Roy Ma, Karen Goddard, Sara Erridge. (2007) Does Intensity Modulation Improve Healthy Tissue Sparing in Stereotactic Radiosurgery of Complex Arteriovenous Malformations?. Medical Dosimetry 32:3, 172-180
CrossRef59
Fran??ois Nataf, Michel Schlienger, Mohammed Bayram, May Ghossoub, Bernard George, Fran??ois-Xavier Roux. (2007) MICROSURGERY OR RADIOSURGERY FOR CEREBRAL ARTERIOVENOUS MALFORMATIONS? A STUDY OF TWO PAIRED SERIES. Neurosurgery 61:1, 39-50
CrossRef60
Shaan M. Raza, Salma Jabbour, Quoc-Anh Thai, Gustavo Pradilla, Lawrence R. Kleinberg, Moody Wharam, Daniele Rigamonti. (2007) Repeat stereotactic radiosurgery for high-grade and large intracranial arteriovenous malformations. Surgical Neurology 68:1, 24-34
CrossRef61
Friedlander, Robert M., . (2007) Arteriovenous Malformations of the Brain. New England Journal of Medicine 356:26, 2704-2712
Full Text62
Chun Po Yen, Peter Varady, Jason Sheehan, Melita Steiner, Ladislau Steiner. (2007) Subtotal obliteration of cerebral arteriovenous malformations after Gamma Knife surgery. Journal of Neurosurgery 106:3, 361-369
CrossRef63
Keisuke Maruyama, Masahiro Shin, Masao Tago, Junji Kishimoto, Akio Morita, Nobutaka Kawahara. (2007) RADIOSURGERY TO REDUCE THE RISK OF FIRST HEMORRHAGE FROM BRAIN ARTERIOVENOUS MALFORMATIONS. Neurosurgery 60:3, 453???459
CrossRef64
Lori C. Jordan, Argye E. Hillis. (2007) Hemorrhagic Stroke in Children. Pediatric Neurology 36:2, 73-80
CrossRef65
Andreas Hartmann, Henning Mast, Jae H. Choi, Christian Stapf, Jay P. Mohr. (2007) Treatment of arteriovenous malformations of the brain. Current Neurology and Neuroscience Reports 7:1, 28-34
CrossRef66
Toru SERIZAWA, Yoshinori HIGUCHI, Junichi ONO, Osamu NAGANO, Takashi SHUTO, Shigeo INOMORI, Hideyo FUJINO, Masaaki YAMAMOTO, Seiji FUKUOKA, Hidefumi JOKURA, Jun KAWAGISHI, Yoshiyasu IWAI, Kazuhiro YAMANAKA. (2007) Natural History of Small Cerebral Arterial Venous Malformations: Analysis of 2000 Cases Treated with Gamma Knife Surgery. Surgery for Cerebral Stroke 35:1, 41-46
CrossRef67
Shoichiro KAWAGUCHI, Toshisuke SAKAKI, Masami IMANISHI, Hiroyuki HASHIMOTO, Takeshi MATSUYAMA, Toshikazu TAKESHIMA, Yeong-Jin KIM, Misato NOBAYASHI. (2007) Management of Spetzler and Martin Grade III to V Arteriovenous Malformations: Usefulness of Surgical Extirpation. Surgery for Cerebral Stroke 35:4, 257-261
CrossRef68
H.-J. Steiger. (2006) Preventive neurosurgery: population-wide check-up examinations and correction of asymptomatic pathologies of the nervous system. Acta Neurochirurgica 148:10, 1075-1083
CrossRef69
Daisuke Itoh, Shigeki Aoki, Keisuke Maruyama, Yoshitaka Masutani, Harushi Mori, Tomohiko Masumoto, Osamu Abe, Naoto Hayashi, Toshiyuki Okubo, Kuni Ohtomo. (2006) Corticospinal Tracts by Diffusion Tensor Tractography in Patients With Arteriovenous Malformations. Journal of Computer Assisted Tomography 30:4, 618-623
CrossRef70
John Sinclair, Steven D. Chang, Iris C. Gibbs, John R. Adler. (2006) Multisession CyberKnife Radiosurgery for Intramedullary Spinal Cord Arteriovenous Malformations. Neurosurgery 58:6, 1081-1089
CrossRef71
Tony Y. Eng, M.K. Boersma, C.D. Fuller, J.Y. Luh, A. Siddiqi, S. Wang, C.R. Thomas. (2006) The Role of Radiation Therapy in Benign Diseases. Hematology/Oncology Clinics of North America 20:2, 523-557
CrossRef72
Kazuhiko Nozaki, Nobuo Hashimoto, Ken-ichiro Kikuta, Yasushi Takagi, Haruhiko Kikuchi. (2006) Surgical Applications to Arteriovenous Malformations Involving the Brainstem. Neurosurgery 58:Supplement 2, ONS-270-ONS-279
CrossRef73
Jian Tu, Marcus A. Stoodley, Michael K. Morgan, Kingsley P. Storer. (2006) Responses of Arteriovenous Malformations to Radiosurgery: Ultrastructural Changes. Neurosurgery 58:4, 749-758
CrossRef74
Christian Stapf, Jay P Mohr, Jae H Choi, Andreas Hartmann, Henning Mast. (2006) Invasive treatment of unruptured brain arteriovenous malformations is experimental therapy. Current Opinion in Neurology 19:1, 63-68
CrossRef75
Hiroaki MATSUMOTO, Tetsuji TAKEDA, Kanehisa KOHNO, Yoshiaki YAMAGUCHI, Keiji KOHNO, Akihiko TAKECHI, Daizo ISHII, Masaru ABIKO, Ushio SASAKI. (2006) Delayed Hemorrhage From Completely Obliterated Arteriovenous Malformation After Gamma Knife Radiosurgery. Neurologia medico-chirurgica 46:4, 186-190
CrossRef76
Masaaki UNO, Kyoko NISHI, Atsuhiko SUZUE, Shinji MANABE, Shunji MATSUBARA, Koichi SATO, Shinji NAGAHIRO. (2006) Strategy and Outcome in Patients with Unruptured Cerebral AVM. Surgery for Cerebral Stroke 34:3, 157-162
CrossRef77
Keisuke MARUYAMA. (2006) Issues in Considering Indication of Radiosurgery for Unruptured Cerebral Arteriovenons Malformations. Surgery for Cerebral Stroke 34:3, 163-166
CrossRef78
Bruce E. Pollock. (2006) Hemorrhage in Unruptured Arteriovenous Malformations. Journal of Neurosurgery 104:1, 172-173
CrossRef79
Toru SERIZAWA, Yoshinori HIGUCHI, Junichi ONO, Toshio MACHIDA, Koichi OKIYAMA, Osamu NAGANO, Naokatsu SAEKI, Takashi SHUTO, Shigeo INOMORI, Hideyo FUJINO, Nobuyuki YASUI, Masaaki YAMAMOTO. (2006) Treatment Selection for Unruptured Small Cerebral Arteriovenous Malformations with Clinical Decision Analysis: Observation, Gamma Knife or Microsurgery?. Surgery for Cerebral Stroke 34:3, 152-156
CrossRef80
J REGIS. (2006) The Risk of Hemorrhage After Radiosurgery for Cerebral Arteriovenous MalformationsMaruyama K, Kawahara N, Shin M, et al (Univ of Tokyo Hosp) N Engl J Med 352:146–153, 2005§. Yearbook of Neurology and Neurosurgery 2006, 236-238
CrossRef81
S BLACK. (2006) The Risk of Hemorrhage After Radiosurgery for Cerebral Arteriovenous MalformationsMaruyama K, Kawahara N, Shin M, et al (Univ of Tokyo Hosp) N Engl J Med 352:146–153, 2005§. Yearbook of Anesthesiology and Pain Management 2006, 98-99
CrossRef82
Chanhung Z Lee, William L Young. (2005) Management of brain arteriovenous malformations. Current Opinion in Anaesthesiology 18:5, 484-489
CrossRef83
Rustam Al-Shahi, Christian Stapf. (2005) The prognosis and treatment of arteriovenous malformations of the brain. Practical Neurology 5:4, 194-205
CrossRef84
Jae H Choi, Jay P Mohr. (2005) Brain arteriovenous malformations in adults. The Lancet Neurology 4:5, 299-308
CrossRef85
Ellegala, Dilantha B., Day, Arthur L., . (2005) Ruptured Cerebral Aneurysms. New England Journal of Medicine 352:2, 121-124
Full Text86
Toru SERIZAWA, Yoshinori HIGUCHI, Junichi ONO, Osamu NAGANO, Naokatsu SAEKI. (2005) Low Dose Gamma Knife Surgery for Small Cerebral Arteriovenous Malformations. Surgery for Cerebral Stroke 33:5, 352-356
CrossRef87
Keisuke MARUYAMA, Masahiro SHIN, Takaaki KIRINO. (2005) Analysis of Complications Based on Long-term Outcomes after Radiosurgery for Cerebral Arteriovenous Malformations. Surgery for Cerebral Stroke 33:5, 347-351
CrossRef
