Abstract
A 32-year-old male, who had endovascular embolization therapy, presented with generalized tonic-clonic seizures. He was treated with adjunctive; Linac-based SRS for post-embolization residual, left, parieto-occipital AVM. The target volume of 2.8 cc received a prescribed dose of 20.0 Gy normalized to 80% isodose line. 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, and perinidal enhancing lesion, in T1 Gadolinium-enhanced study, denoting radiation-induced parenchymal changes. At 36 months post-SRS, computerized tomography angiography (CTA) showed residual small AVM nidus. At last radiological follow-up (82 months post-SRS), CTA showed incomplete obliteration with residual, but, much smaller AVM nidus. The radiosurgery treatment was successful and without complications. At last clinical follow-up (82 months post-SRS), the patient had controlled seizures with lower dose of anticonvulsant medication. The patient was offered surgery, repeat radiosurgery, or endovascular embolization for the post-radiosurgery residual, non-obliterated, small AVM nidus.
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Keywords
- Arteriovenous malformation
- Cerebellar AVM
- Embolization
- Seizures
- Stereotactic radiosurgery
- Linear accelerator
- Linac-based radiosurgery
- Adjunctive SRS
- Computerized tomography angiography
- Incomplete nidus obliteration
- Perinidal edema
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Demographics: Male; 32 years
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Initial Presentation: Seizures for 2 months before radiosurgery treatment
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Diagnosis: Parieto-occipital AVM
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Pre-radiosurgery Treatment: Endovascular embolization; 3 weeks before radiosurgery treatment
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Pre-radiosurgery Presentation: Seizures (generalized tonic-clonic)
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Radiosurgery Treatment:
Adjunctive; Linac-based SRS for post-embolization residual, left, parieto-occipital AVM
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Radiosurgery Dosimetry:
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Target volume: 2.8 cc
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Marginal dose: 20.0 Gy
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Marginal isodose: 80%
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Maximum dose: 25.0 Gy
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Minimum dose: 18.1 Gy
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Average dose: 23.9 Gy
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Number of isocenters: 1
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Follow-Up Period: 82 months post-SRS
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Clinical Outcome:
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6 months post-SRS: Persistent seizures with medication
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18 months post-SRS: Decreased seizures frequency with medication
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30 months post-SRS: Controlled seizures with medication
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48 months post-SRS: Controlled seizures with lower dose of medication
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82 months post-SRS: Sustainable control of seizures with lower dose of medication
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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 (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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Appearance of perinidal enhancing lesion, in T1 Gadolinium-enhanced study, denoting radiation-induced parenchymal changes
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18 months post-SRS (MRI):
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More decrease in size of AVM nidus
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Increased perinidal high signal in T2 and FLAIR studies
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Increase in size of perinidal enhancing lesion, in T1 Gadolinium-enhanced study
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24 months post-SRS (MRI):
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More decrease in size of AVM nidus
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Resolving perinidal high signal in T2 and FLAIR studies
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Decrease in size of perinidal enhancing lesion, in T1 Gadolinium-enhanced study
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36 months post-SRS (MRI):
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Stationary decreased size of AVM nidus
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Mild residual perinidal high signal in T2 and FLAIR studies
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Resolution of perinidal enhancement, in T1 Gadolinium-enhanced study
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36 months post-SRS (CTA): Residual small AVM nidus
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48 months post-SRS (CTA): Residual smaller AVM nidus
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82 months post-SRS (CTA): Residual much smaller AVM nidus
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Post-radiosurgery Treatment: Continued anti-convulsant medication. The patient is scheduled for conventional cerebral angiography and will be offered surgery, repeat radiosurgery, or endovascular embolization for the post-radiosurgery residual, non-obliterated, small AVM nidus
Further Reading
Daou BJ, Palmateer G, Wilkinson DA, et al. Radiation-induced imaging changes and cerebral edema following stereotactic radiosurgery for brain AVMs. Am J Neuroradiol. 2021;42:82. https://doi.org/10.3174/ajnr.A6880.
Lee CC, Chen CJ, Ball B, et al. Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study. J Neurosurg. 2015;123(1):120–35.
Schäuble B, Cascino GD, Pollock BE, et al. Seizure outcomes after stereotactic radiosurgery for cerebral arteriovenous malformations. Neurology. 2004;63(4):683–7.
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). Previously Embolized Arteriovenous Malformation (AVM). In: NeuroRadiosurgery: Case Review Atlas. Springer, Cham. https://doi.org/10.1007/978-3-031-16199-5_12
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DOI: https://doi.org/10.1007/978-3-031-16199-5_12
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