Abstract
A 37-year-old male, presented with chronic headache, was treated with upfront (primary); Linac-based stereotactic radiosurgery (SRS) for right, rolandic (motor cortex) AVM. The target volume of 6.3 cc received a marginal dose of 15.0 Gy normalized to 75% isodose line. Serial post-SRS follow-up MRIs showed a slight reduction in the size of AVM nidus, coupled with perinidal high signal in T2 and FLAIR studies, denoting vasogenic edema. At 36 months post-SRS, MRI showed perinidal heterogeneously enhancing focal encephalomalacia in T1 Gadolinium-enhanced study. At last follow-up (62 months post-SRS), computerized tomography angiography (CTA) showed residual smaller AVM nidus. The post-SRS follow-up period went uneventful; however, the patient is still having attaches of mild headache. Extended follow-up to watch for delayed complete AVM nidus obliteration was advised, before deciding repeat radiosurgery treatment.
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Keywords
- Arteriovenous malformation
- Motor cortex AVM
- Rolandic AVM
- Stereotactic radiosurgery
- Linear accelerator
- Linac-based radiosurgery
- Upfront SRS
- Computerized tomography angiography
- Perinidal edema
- Encephalomalacia
- Delayed nidus obliteration
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Demographics: Male; 37 years
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Initial Presentation: Chronic headache
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Diagnosis: Rolandic AVM
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Pre-radiosurgery Treatment: None
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Pre-radiosurgery Presentation: Chronic headache
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Radiosurgery Treatment:
Upfront (primary); Linac-based SRS for right, rolandic (motor cortex) AVM
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Radiosurgery Dosimetry:
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Target volume: 6.3 cc
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Marginal dose: 15.0 Gy
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Marginal isodose: 75%
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Maximum dose: 20.6 Gy
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Minimum dose: 13.5 Gy
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Average dose: 18.9 Gy
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Number of isocenters: 1
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Follow-Up Period: 62 months post-SRS
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Clinical Outcome:
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6 months post-SRS: Persistence of annoying attaches of headache
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24 months post-SRS: Slightly improving headaches with medications
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60 months post-SRS: Persistence of mild attaches of headache
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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): Stationary size of AVM nidus
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24 months post-SRS (MRI):
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Stationary 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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36 months post-SRS (MRI):
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Stationary size of AVM nidus
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Increased perinidal high signal in T2 and FLAIR studies
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Appearance of perinidal focal encephalomalacia showing heterogeneous enhancement in T1 Gadolinium-enhanced study
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60 months post-SRS (MRI):
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Slight decrease in size of AVM nidus
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Persistent increased perinidal high signal in T2 and FLAIR studies
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Persistence of perinidal heterogeneously enhancing focal encephalomalacia in T1 Gadolinium-enhanced study
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61 months post-SRS (CT):
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Persistence of perinidal heterogeneously enhancing focal encephalomalacia in contrast-enhanced study
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62 months post-SRS (CTA): Residual smaller AVM nidus
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Post-radiosurgery Treatment: Watchful waiting for delayed complete obliteration of the residual AVM nidus during an extended follow-up period before deciding repeat radiosurgery treatment
Further Reading
Cohen-Inbar O, Starke RM, Paisan G, et al. Early versus late arteriovenous malformation responders after stereotactic radiosurgery: an international multicenter study. J Neurosurg. 2017;127(3):503–11.
Ellis TL, Friedman WA, Bova FJ, et al. Analysis of treatment failure after radiosurgery for arteriovenous malformations. J Neurosurg. 1998;89(1):104–11.
Gallina P, Merienne L, Meder JF, et al. Failure in radiosurgery treatment of cerebral arteriovenous malformations. Neurosurgery. 1998;42(5):996–1002.
Hadjipanayis CG, Levy EI, Niranjan A, et al. Stereotactic radiosurgery for motor cortex region arteriovenous malformations. Neurosurgery. 2001;48(1):70–7.
Levegrün S, Hof H, Essig M, et al. Radiation-induced changes of brain tissue after radiosurgery in patients with arteriovenous malformations: dose/volume-response relations. Strahlenther Onkol. 2004;180(12):758–67.
Zabel-du Bois A, Milker-Zabel S, Huber P, et al. Stereotactic linac-based radiosurgery in the treatment of cerebral arteriovenous malformations located deep, involving corpus callosum, motor cortex, or brainstem. Int J Radiat Oncol Biol Phys. 2006;64(4):1044–8.
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Abdelaziz, O.S., De Salles, A.A.F. (2023). Rolandic Arteriovenous Malformation (AVM). In: NeuroRadiosurgery: Case Review Atlas. Springer, Cham. https://doi.org/10.1007/978-3-031-16199-5_4
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DOI: https://doi.org/10.1007/978-3-031-16199-5_4
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