Ruptured Thoracolumbar Perimedullary Arteriovenous Fistula during Pregnancy Complicated by Cerebral Subarachnoid Hemorrhage and Brainstem Hematoma: A Case Report.

Intradural spinal arteriovenous fistulas (sAVF) are spinal vascular lesions that usually manifest due to myelopathy or local symptoms caused by venous congestion and ischemia. In addition, perimedullary arteriovenous fistulas (PMAVF) in particular may rupture and cause subarachnoid or intramedullary hemorrhage along with relevant symptoms. Subarachnoid hemorrhage (SAH) can propagate into cranial space with clinically dominant symptoms and signs of typical aneurysmal intracranial SAH. The standard workup for cerebral SAH, after excluding an intracranial source of hemorrhage, is usually limited to a cervical spine MRI; therefore, thoracolumbar sources of hemorrhage can be missed, or their diagnosis may be delayed. Here we present a case of a pregnant patient who presented with cerebral SAH. The source of hemorrhage was not initially identified, leading to a presumptive diagnosis of benign pretruncal non-aneurysmal SAH. The correct diagnosis of spinal thoracolumbar PMAVF was revealed 2.5 months later due to the progression of local symptoms. While the diagnosis was being refined and endovascular treatment was being planned (but delayed due to pregnancy), there was a recurrence of intraconal hemorrhage followed by brainstem hemorrhage. This led to significant clinical deterioration. The PMAVF was then treated microsurgically and the patient experienced partial recovery.

Stereotactic Radiosurgery for Cavernous Sinus Versus Noncavernous Sinus Dural Arteriovenous Fistulas: Outcomes and Outcome Predictors.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) can be categorized based on location. OBJECTIVE: To compare stereotactic radiosurgery (SRS) outcomes between cavernous sinus (CS) and non-CS DAVFs and to identify respective outcome predictors. METHODS: This is a retrospective study of DAVFs treated with SRS between 1988 and 2016 at 10 institutions. Patients' variables, DAVF characters, and SRS parameters were included for analyses. Favorable clinical outcome was defined as angiography-confirmed obliteration without radiological radiation-induced changes (RIC) or post-SRS hemorrhage. Other outcomes were DAVFs obliteration and adverse events (including RIC, symptomatic RIC, and post-SRS hemorrhage). RESULTS: The overall study cohort comprised 131 patients, including 20 patients with CS DAVFs (15%) and 111 patients with non-CS DAVFs (85%). Rates of favorable clinical outcome were comparable between the 2 groups (45% vs 37%, P = .824). Obliteration rate after SRS was higher in the CS DAVFs group, even adjusted for baseline difference (OR = 4.189, P = .044). Predictors of favorable clinical outcome included higher maximum dose (P = .014) for CS DAVFs. Symptomatic improvement was associated with obliteration in non-CS DAVFs (P = .005), but symptoms improved regardless of whether obliteration was confirmed in CS DAVFs. Non-CS DAVFs patients with adverse events after SRS were more likely to be male (P = .020), multiple arterial feeding fistulas (P = .018), and lower maximum dose (P = .041). CONCLUSION: After SRS, CS DAVFs are more likely to obliterate than non-CS ones. Because these 2 groups have different total predictors for clinical and radiologic outcomes after SRS, they should be considered as different entities.

A Proposed Grading Scale for Predicting Outcomes After Stereotactic Radiosurgery for Dural Arteriovenous Fistulas.

BACKGROUND: There are presently no grading scales that specifically address the outcomes of cranial dural arteriovenous fistula (dAVF) after stereotactic radiosurgery (SRS). OBJECTIVE: To design a practical grading system that would predict outcomes after SRS for cranial dAVFs. METHODS: From the International Radiosurgery Research Foundation (University of Pittsburgh [41 patients], University of Pennsylvania [6 patients], University of Sherbrooke [2 patients], University of Manitoba [1 patient], West Virginia University [2 patients], University of Puerto Rico [1 patient], Beaumont Health System 1 [patient], Na Homolce Hospital [13 patients], the University of Virginia [48 patients], and Yale University [6 patients]) centers, 120 patients with dAVF treated with SRS were included in the study. The factors predicting favorable outcome (obliteration without post-SRS hemorrhage) after SRS were assessed using logistic regression analysis. These factors were pooled with the factors that were found to be predictive of obliteration from 7 studies with 736 patients after a systematic review of literature. These were entered into stepwise multiple regression and the best-fit model was identified. RESULTS: Based on the predictive model, 3 factors emerged to develop an SRS scoring system: cortical venous reflux (CVR), prior intracerebral hemorrhage (ICH), and noncavernous sinus location. Class I (score of 0-1 points) predicted the best favorable outcome of 80%. Class II patients (2 points score) had an intermediate favorable outcome of 57%, and class III (score 3 points) had the least favorable outcome at 37%. The ROC analysis showed better predictability to prevailing grading systems (AUC = 0.69; P = .04). Kaplan-Meier analysis showed statistically significant difference between the 3 subclasses of the proposed grading system for post-SRS dAVF obliteration (P = .001). CONCLUSION: The proposed dAVF grading system incorporates angiographic, anatomic, and clinical parameters and improves the prediction of the outcomes following SRS for dAVF as compared to the existing scoring systems.

Hemorrhage risk of cerebral dural arteriovenous fistulas following Gamma Knife radiosurgery in a multicenter international consortium.

OBJECTIVE: The authors performed a study to evaluate the hemorrhagic rates of cerebral dural arteriovenous fistulas (dAVFs) and the risk factors of hemorrhage following Gamma Knife radiosurgery (GKRS). METHODS: Data from a cohort of patients undergoing GKRS for cerebral dAVFs were compiled from the International Radiosurgery Research Foundation. The annual posttreatment hemorrhage rate was calculated as the number of hemorrhages divided by the patient-years at risk. Risk factors for dAVF hemorrhage prior to GKRS and during the latency period after radiosurgery were evaluated in a multivariate analysis. RESULTS: A total of 147 patients with dAVFs were treated with GKRS. Thirty-six patients (24.5%) presented with hemorrhage. dAVFs that had any cortical venous drainage (CVD) (OR = 3.8, p = 0.003) or convexity or torcula location (OR = 3.3, p = 0.017) were more likely to present with hemorrhage in multivariate analysis. Half of the patients had prior treatment (49.7%). Post-GRKS hemorrhage occurred in 4 patients, with an overall annual risk of 0.84% during the latency period. The annual risks of post-GKRS hemorrhage for Borden type 2-3 dAVFs and Borden type 2-3 hemorrhagic dAVFs were 1.45% and 0.93%, respectively. No hemorrhage occurred after radiological confirmation of obliteration. Independent predictors of hemorrhage following GKRS included nonhemorrhagic neural deficit presentation (HR = 21.6, p = 0.027) and increasing number of past endovascular treatments (HR = 1.81, p = 0.036). CONCLUSIONS: Patients have similar rates of hemorrhage before and after radiosurgery until obliteration is achieved. dAVFs that have any CVD or are located in the convexity or torcula were more likely to present with hemorrhage. Patients presenting with nonhemorrhagic neural deficits and a history of endovascular treatments had higher risks of post-GKRS hemorrhage.

A Propensity Score-Matched Cohort Analysis of Outcomes After Stereotactic Radiosurgery in Older versus Younger Patients with Dural Arteriovenous Fistula: An International Multicenter Study.

OBJECTIVE: This study aims to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in older patients (≥65 years) compared with younger patients (age <65 years). METHODS: Two groups with a total of 96 patients were selected from a database of 133 patients with dAVF from 9 international medical centers with a minimum 6 months follow-up. A 1:2 propensity matching was performed by nearest-neighbor matching criteria based on sex, Borden grade, maximum radiation dose given, and location. The older cohort consisted of 32 patients and the younger cohort consisted of 64 patients. The mean overall follow-up in the combined cohort was 42.4 months (range, 6-210 months). RESULTS: In the older cohort, a transverse sinus location was found to significantly predict dAVF obliteration (P = 0.01). The post-SRS actuarial 3-year and 5-year obliteration rates were 47.7% and 78%, respectively. There were no cases of post-SRS hemorrhage. In the younger cohort, the cavernous sinus location was found to significantly predict obliteration (P = 0.005). The 3-year and 5-year actuarial obliteration rates were 56% and 70%, respectively. Five patients (7.8%) hemorrhaged after SRS. Margin dose ≥25 Gy was predictive of unfavorable outcome. The obliteration rate (P = 0.3), post-SRS hemorrhage rate (P = 0.16), and persistent symptoms after SRS (P = 0.83) were not statistically different between the 2 groups. CONCLUSIONS: SRS achieves obliteration in most older patients with dAVF, with an acceptable rate of complication. There was no increased risk of postradiosurgery complications in the older cohort compared with the younger patients.

Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium.

OBJECTIVE: In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome. METHODS: Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose. RESULTS: A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5-18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration. CONCLUSIONS: GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

Comparison of CT and MR imaging in ischemic stroke.

BACKGROUND: Cerebrovascular disease represents a major source of global mortality and morbidity. Imaging examinations play a critical role in the management of stroke patients, from establishing the initial diagnosis to determining and guiding further treatment. METHODS: In this article, current CT and MRI methods employed in the management of stroke patients are reviewed, with an emphasis on ischemic stroke. RESULTS: The advantages and disadvantages of these techniques are discussed, a number of cases emphasizing key points are presented, and a comparison between modern CT and MRI techniques is outlined. CONCLUSION: The major drawback of CT is the high radiation dose, while in MRI it is the more complicated and time-consuming aspect of the examination. MAIN MESSAGES: • Cerebrovascular disease represents a major source of global mortality and morbidity • Imaging examinations play a critical role in the management of stroke patients • The penumbra may be seen with both CT and MRI; however, this concept may be overly simplistic • The major drawback of CT is the high radiation dose, while MRI is a more complicated examination.

Gamma Knife surgery for benign meningioma.

OBJECT: Meningioma is the most frequent benign tumor treated with Gamma Knife surgery (GKS); however, the assessment of its efficacy and safety in slow-growing tumors is an ongoing process, requiring analysis of long-term results. METHODS: Three hundred sixty-eight patients harboring 400 meningiomas treated between 1992 and 1999 at Na Homolce Hospital were evaluated. The median patient age was 57 years (range 18-84 years). The median tumor volume was 4.4 cm3 (range 0.11-44.9 cm3). The median tumor margin dose to the 50% isodose line was 12.55 Gy (range 6.5-24 Gy). Descriptive analysis was performed in 331 patients (90%); 325 patients had a follow-up longer than 24 months (median 60 months), and six patients were included because of posttreatment complications. The volume of treated tumors decreased in 248 cases (69.7%), remained the same in 99 (27.8%), and increased in nine (2.5%). The actuarial tumor control rate was 97.9% at 5 years post-GKS. Perilesional edema after radiosurgery was confirmed on neuroimaging in 51 patients (15.4%). The temporary and permanent morbidity rates after radiosurgery were 10.2 and 5.7%, respectively. RESULTS: A significantly higher incidence of tumor volume increase was observed in men compared with women and in tumors treated with a margin dose lower than 12 Gy. Significant risk factors for edema included an age greater than 60 years, no previous surgery, perilesional edema before radiosurgery, a tumor volume greater than 10 cm3, a tumor location in the anterior fossa, and a margin dose greater than 16 Gy. CONCLUSIONS: Stereotactic radiosurgery is a safe method of treatment for meningiomas. A minimum margin dose of 12 to 16 Gy seems to represent the therapeutic window for benign meningiomas with a high tumor control rate in a mid-term follow-up period.

Arteriovenous malformations after Leksell gamma knife radiosurgery: rate of obliteration and complications.

OBJECTIVE: Although relevant information exists regarding the chance of obliterating arteriovenous malformations (AVMs) using radiosurgery, the overall chance of cure after gamma knife radiosurgery is usually only extrapolated from a portion of all monitored patients. This chance and the risks involved in radiosurgery, including repeat treatment when necessary in a defined population of treated patients, were analyzed in our study. METHODS: Between October 1992 and June 2000, gamma knife radiosurgery was performed on 330 patients with AVMs. The volume of the AVM nidus ranged from 0.15 to 28.6 cm (median, 3.9 cm). When complete obliteration was not achieved within 3 years, repeat radiosurgery was performed on 76 patients. The volume of the nidus for the second treatment ranged from 0.09 to 16.8 cm (median 2.9 cm). The result was reviewed in 300 (91%) patients after the first round of treatment and in 68 (89.5%) after the second round of treatment. RESULTS: AVM obliteration was achieved in 222 (74%) patients after the first round of radiosurgery and in 47 (69%) after the second. The overall chance of cure was 92% (269 patients). Final angiography verified complete obliteration by 12 to 96 months (median, 25 mo) after initial radiosurgery. Smaller volume AVMs and the application of a higher radiation dose resulted in a higher chance of obliteration. The risk of rebleeding after radiosurgery was 2.1% annually until full obliteration, and the overall mortality from rebleeding was 1%. The risk of permanent morbidity after the first and second radiosurgery treatments were 2.7 and 2.9%, respectively. The cumulative risk of morbidity in both groups of patients was 3.4%. CONCLUSION: Although one-quarter of the patients required that the treatment be repeated, gamma knife radiosurgery can offer a high cure rate for patients treated for AVMs with a low risk of morbidity and mortality from rebleeding during the latent period.