Abstract
A 14-year-old boy, who had two previous attacks of intraventricular hemorrhage, presented asymptomatic and neurologically intact, after complete recovery from coma induced by last hemorrhage. He was treated with upfront (primary); Linac-based SRS for right basal ganglia (lentiform nucleus) AVM. The target volume of 3.2 cc received a marginal dose of 18.0 Gy normalized to 80% isodose line, in a 2-isocenter plan. Serial post-SRS follow-up MRIs showed a progressive reduction in the size of AVM nidus till its non-visualization at 25 months post-SRS. The follow-up MRIs also showed perinidal high signal in T2 and FLAIR studies, denoting vasogenic edema, and periventricular focal and minimally enhancing encephalomalacia, in T1 Gadolinium-enhanced study, at the site of prior AVM nidus. At last follow-up (65 months post-SRS), computerized tomography angiography (CTA) documented complete obliteration of AVM nidus. The radiosurgery treatment was successful, and the patient remained asymptomatic and neurologically intact throughout the entire follow-up period.
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Keywords
- Arteriovenous malformation
- Basal ganglia AVM
- Pediatric AVM
- Deep AVM
- Stereotactic radiosurgery
- Linear accelerator
- Linac-based radiosurgery
- Primary SRS
- Computerized tomography angiography
- Perinidal edema
- Nidus obliteration
- Encephalomalacia
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Demographics: Male; 14 years
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Initial Presentation: Hemorrhage (intraventricular), which occurred twice; at 2 years and 8 months before radiosurgery treatment
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Diagnosis: Basal ganglia AVM
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Pre-radiosurgery Treatment: None
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Pre-radiosurgery Presentation: Asymptomatic and neurologically intact, after complete recovery from coma induced by last hemorrhage
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Radiosurgery Treatment:
Upfront (primary); Linac-based SRS for right basal ganglia (lentiform nucleus) AVM
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Radiosurgery Dosimetry:
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Target volume: 3.2 cc
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Marginal dose: 18.0 Gy
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Marginal isodose: 80%
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Maximum dose: 39.8 Gy
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Minimum dose: 14.2 Gy
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Average dose: 26.7 Gy
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Number of isocenters: 2
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Maximum dose to brain stem: 6.7 Gy
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Follow-Up Period: 65 months post-SRS
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Clinical Outcome: Asymptomatic and neurologically intact throughout the entire follow-up period
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Complications: None
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Radiological Outcome:
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7 months post-SRS (MRI and MRA): Stationary size of AVM nidus
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14 months post-SRS (MRI):
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Marked decrease in size of AVM nidus
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Appearance of right periventricular perinidal high signal in T2 and FLAIR studies, denoting vasogenic edema
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25 months post-SRS (MRI):
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Non-visualized AVM nidus
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Resolving right periventricular perinidal high signal in T2 and FLAIR studies
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Appearance of right periventricular focal encephalomalacia, showing minimal enhancement in T1 Gadolinium-enhanced study, at the site of prior AVM nidus
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65 months post-SRS (CTA): Complete obliteration of AVM nidus
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Post-radiosurgery Treatment: None
Further Reading
Andrade-Souza YM, Zadeh G, Scora D, et al. Radiosurgery for basal ganglia, internal capsule, and thalamus arteriovenous malformation. Neurosurgery. 2005;56:56–64.
Cohen-Gadol AA, Pollock BE. Radiosurgery for arteriovenous malformations in children. J Neurosurg. 2006;104(6):388–91.
Fleetwood IG, Marcellus ML, Levy RP, et al. Deep arteriovenous malformations of the basal ganglia and thalamus. J Neurosurg. 2003;98:747–50.
Ilyas A, Chen CJ, Ding D, et al. Radiation-induced changes after stereotactic radiosurgery for brain arteriovenous malformations: a systematic review and meta-analysis. Neurosurgery. 2018;83(3):365–76.
Mobin F, De Salles AAF, Abdelaziz O, et al. Stereotactic radiosurgery of cerebral arteriovenous malformations: appearance of perinidal T2 hyperintensity signal as a predictor of favorable treatment response. Stereotact Funct Neurosurg. 1999;73(1–4):50–9.
Pollock BE, Gorman DA, Brown PD. Radiosurgery for arteriovenous malformations of the basal ganglia, thalamus, and brainstem. J Neurosurg. 2004;100:210–4.
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Abdelaziz, O.S., De Salles, A.A.F. (2023). Basal Ganglia Arteriovenous Malformation (AVM). In: NeuroRadiosurgery: Case Review Atlas. Springer, Cham. https://doi.org/10.1007/978-3-031-16199-5_8
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DOI: https://doi.org/10.1007/978-3-031-16199-5_8
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