Abstract
A 41-year-old female, who had two sessions of endovascular embolization therapy, presented with sequalae of previous embolization (vertigo, left-sided tinnitus, and deafness). She was treated with adjunctive; Linac-based SRS for post-embolization residual, left, cerebellar hemisphere AVM. The target volume of 3.4 cc received a prescribed dose of 19.0 Gy normalized to 75% isodose line. The maximum dose to brain stem was 21.8 Gy. Serial post-SRS follow-up MRIs showed progressive reduction in the size of AVM nidus, coupled with perinidal high signal in T2 and FLAIR studies, denoting vasogenic edema. At 24 months post-SRS, computerized tomography angiography (CTA) showed residual smaller AVM nidus. At last follow-up (32 months post-SRS), conventional cerebral angiography documented complete obliteration of the AVM nidus. The post-SRS follow-up period went uneventful and without complications. The radiosurgery treatment was successful. The patient reported improvement of vertigo, however, prior left-sided tinnitus and deafness remained unchanged.
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Keywords
- Arteriovenous malformation
- Cerebellar AVM
- Embolization
- Stereotactic radiosurgery
- Linear accelerator
- Linac-based radiosurgery
- Adjunctive SRS
- Computerized tomography angiography
- Cerebral angiography
- Nidus obliteration
- Perinidal edema
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Demographics: Female; 41 years
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Initial Presentation: Headache for 11 months before radiosurgery treatment
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Diagnosis: Cerebellar AVM
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Pre-radiosurgery Treatment: Endovascular embolization twice; at 10 and 3 months before radiosurgery treatment
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Pre-radiosurgery Presentation: Vertigo, left-sided deafness, and left-sided tinnitus (all are sequelae of previous embolization)
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Radiosurgery Treatment:
Adjunctive; linac-based SRS for post-embolization residual, left, cerebellar hemisphere AVM
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Radiosurgery Dosimetry:
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Target volume: 3.4 cc
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Marginal dose: 19.0 Gy
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Marginal isodose: 75%
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Maximum dose: 26.8 Gy
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Minimum dose: 12.3 Gy
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Average dose: 24.6 Gy
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Number of isocenters: 1
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Maximum dose to brain stem: 21.8 Gy
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Follow-Up Period: 32 months post-SRS
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Clinical Outcome:
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6 months post-SRS:
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Minimal improvement of vertigo and left-sided tinnitus
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Stationary left-sided deafness
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12 months post-SRS:
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More improvement of vertigo and left-sided tinnitus
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Stationary left-sided deafness
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18 months post-SRS:
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Improved vertigo
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Stationary residual left sided tinnitus
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Stationary left-sided deafness
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32 months post-SRS:
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Sustainable improvement of vertigo
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Stationary residual left-sided tinnitus
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Stationary left-sided deafness
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Complications: None
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Radiological Outcome:
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6 months post-SRS (MRI): Stationary size of AVM nidus
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12 months post-SRS (CTA): Residual small AVM nidus
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18 months post-SRS (MRI):
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Decrease in size of AVM nidus
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Appearance of perinidal high signal in T2 and FLAIR studies, denoting vasogenic edema
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19 months post-SRS (MRA): Residual small AVM nidus
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24 months post-SRS (CTA): Residual smaller AVM nidus
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32 months post-SRS (conventional angiography): Complete obliteration of AVM nidus
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Post-radiosurgery Treatment: None
Further Reading
Abdelaziz OS, Abdelaziz A, Rostom Y, et al. LINAC radiosurgery of intracranial arteriovenous malformations: a single-center initial experience. Neurosurg Q. 2011;21:85–96. https://doi.org/10.1097/WNQ.0b013e31820cd2ea.
Cohen-Inbar O, Stark RM, Kano H, et al. Stereotactic radiosurgery for cerebellar arteriovenous malformations: an international multicenter study. J Neurosurg. 2017;127(3):512–21.
Van den Berg R, Buis DR, Lagerwaard FJ, et al. Extensive white matter changes after stereotactic radiosurgery for brain arteriovenous malformations: a prognostic sign for obliteration? Neurosurgery. 2008;63(6):1064–9.
Yan D, Chen Y, Li Z, et al. Stereotactic radiosurgery with vs. without prior embolization for brain arteriovenous malformations: a propensity score matching analysis. Front Neurol. 2021;12:752164. https://doi.org/10.3389/fneur.2021.752164.
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Abdelaziz, O.S., De Salles, A.A.F. (2023). Cerebellar Arteriovenous Malformation (AVM). In: NeuroRadiosurgery: Case Review Atlas. Springer, Cham. https://doi.org/10.1007/978-3-031-16199-5_11
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DOI: https://doi.org/10.1007/978-3-031-16199-5_11
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