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Title: Delineation of brain AVMs on MR-Angiography for the purpose of stereotactic radiosurgery

Abstract

Purpose: To assess the dosimetric consequences of brain arteriovenous malformation (bAVM) delineation on magnetic resonance angiography (MRA) for the purpose of stereotactic radiosurgery. Methods and Materials: Three observers contoured a bAVM in 20 patients, using digital subtraction angiography (V{sub DSA}) and three-dimensional time-of-flight MRA (V{sub MRA}). Displacement between contours was calculated. Agreement and differences between observers and imaging modalities were assessed. A standardized treatment plan with dynamic conformal arcs was generated and dosimetric coverage of all contours and the volume of normal brain tissue within the high dose region was determined. Results: The generalized reliability coefficient was 'fair' for target volume (0.79), but 'poor' for displacement (0.35). V{sub MRA} was larger than V{sub DSA} (5.0 vs. 4.0 mL, p = 0.001). No difference in displacement was found (2.8 vs. 2.5 mm, p = 0.156). Dosimetric coverage of V{sub MRA} was 62.9% (95% CI, 56.9-68.8) when V{sub DSA} was used as planning target volume, and coverage of V{sub DSA} was 83.5% (95% CI, 78.1-88.8) when V{sub MRA} was used for planning (p < 0.001). The mean volume of normal brain within the 80% isodose was larger when the bAVM was delineated on MRA (0.7 vs. 1.0 mL (p = 0.02) formore » targets {<=}3 mL and 3.7 vs. 7.0 mL (p = 0.01) for targets >3 mL). Conclusions: Brain arteriovenous malformations delineated on MRA are larger and more randomly displaced. However, for bAVMs {<=}3 mL, the difference in volume of normal brain tissue within the high-dose region does not seem to be clinically relevant. Therefore, MRA-images might be used as the sole imaging modality for the radiosurgical treatment of bAVMs {<=}3 mL when the bAVM is located in a noneloquent position.« less

Authors:
 [1];  [2];  [3];  [4];  [5];  [4];  [2];  [3]
  1. Department of Neurosurgery, VU University Medical Center, Amsterdam (Netherlands). E-mail: dr.buis@vumc.nl
  2. Department of Radiation Oncology, VU University Medical Center, Amsterdam (Netherlands)
  3. Department of Neurosurgery, VU University Medical Center, Amsterdam (Netherlands)
  4. Department of Radiology, VU University Medical Center, Amsterdam (Netherlands)
  5. Department of Clinical Epidemiology and Biostatistics, VU University Medical Center, Amsterdam (Netherlands)
Publication Date:
OSTI Identifier:
20850329
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 67; Journal Issue: 1; Other Information: DOI: 10.1016/j.ijrobp.2006.08.075; PII: S0360-3016(06)02836-7; Copyright (c) 2007 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BIOMEDICAL RADIOGRAPHY; BLOOD VESSELS; BRAIN; IMAGES; MALFORMATIONS; NMR IMAGING; PATIENTS; PLANNING; RADIATION DOSES; RADIOTHERAPY; RELIABILITY; SURGERY; TIME-OF-FLIGHT METHOD

Citation Formats

Buis, Dennis R., Lagerwaard, Frank J., Dirven, Clemens M.F., Barkhof, Frederik, Knol, Dirk L., Berg, Rene van den, Slotman, Ben J., and Vandertop, W. Peter. Delineation of brain AVMs on MR-Angiography for the purpose of stereotactic radiosurgery. United States: N. p., 2007. Web. doi:10.1016/j.ijrobp.2006.08.075.
Buis, Dennis R., Lagerwaard, Frank J., Dirven, Clemens M.F., Barkhof, Frederik, Knol, Dirk L., Berg, Rene van den, Slotman, Ben J., & Vandertop, W. Peter. Delineation of brain AVMs on MR-Angiography for the purpose of stereotactic radiosurgery. United States. doi:10.1016/j.ijrobp.2006.08.075.
Buis, Dennis R., Lagerwaard, Frank J., Dirven, Clemens M.F., Barkhof, Frederik, Knol, Dirk L., Berg, Rene van den, Slotman, Ben J., and Vandertop, W. Peter. Mon . "Delineation of brain AVMs on MR-Angiography for the purpose of stereotactic radiosurgery". United States. doi:10.1016/j.ijrobp.2006.08.075.
@article{osti_20850329,
title = {Delineation of brain AVMs on MR-Angiography for the purpose of stereotactic radiosurgery},
author = {Buis, Dennis R. and Lagerwaard, Frank J. and Dirven, Clemens M.F. and Barkhof, Frederik and Knol, Dirk L. and Berg, Rene van den and Slotman, Ben J. and Vandertop, W. Peter},
abstractNote = {Purpose: To assess the dosimetric consequences of brain arteriovenous malformation (bAVM) delineation on magnetic resonance angiography (MRA) for the purpose of stereotactic radiosurgery. Methods and Materials: Three observers contoured a bAVM in 20 patients, using digital subtraction angiography (V{sub DSA}) and three-dimensional time-of-flight MRA (V{sub MRA}). Displacement between contours was calculated. Agreement and differences between observers and imaging modalities were assessed. A standardized treatment plan with dynamic conformal arcs was generated and dosimetric coverage of all contours and the volume of normal brain tissue within the high dose region was determined. Results: The generalized reliability coefficient was 'fair' for target volume (0.79), but 'poor' for displacement (0.35). V{sub MRA} was larger than V{sub DSA} (5.0 vs. 4.0 mL, p = 0.001). No difference in displacement was found (2.8 vs. 2.5 mm, p = 0.156). Dosimetric coverage of V{sub MRA} was 62.9% (95% CI, 56.9-68.8) when V{sub DSA} was used as planning target volume, and coverage of V{sub DSA} was 83.5% (95% CI, 78.1-88.8) when V{sub MRA} was used for planning (p < 0.001). The mean volume of normal brain within the 80% isodose was larger when the bAVM was delineated on MRA (0.7 vs. 1.0 mL (p = 0.02) for targets {<=}3 mL and 3.7 vs. 7.0 mL (p = 0.01) for targets >3 mL). Conclusions: Brain arteriovenous malformations delineated on MRA are larger and more randomly displaced. However, for bAVMs {<=}3 mL, the difference in volume of normal brain tissue within the high-dose region does not seem to be clinically relevant. Therefore, MRA-images might be used as the sole imaging modality for the radiosurgical treatment of bAVMs {<=}3 mL when the bAVM is located in a noneloquent position.},
doi = {10.1016/j.ijrobp.2006.08.075},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 1,
volume = 67,
place = {United States},
year = {Mon Jan 01 00:00:00 EST 2007},
month = {Mon Jan 01 00:00:00 EST 2007}
}
  • Purpose: Stereotactic radiation surgery (SRS) is one of the therapeutic modalities currently available to treat cerebral arteriovenous malformations (AVM). Conventionally, magnetic resonance imaging (MRI) and MR angiography (MRA) and digital subtraction angiography (DSA) are used in combination to identify the target volume for SRS treatment. The purpose of this study was to evaluate the use of C-arm cone beam computed tomography (CBCT) in the treatment planning of SRS for cerebral AVMs. Methods and Materials: Sixteen consecutive patients treated for brain AVMs at our institution were included in this retrospective study. Prior to treatment, all patients underwent MRA, DSA, and C-arm CBCT.more » All images were coregistered using the GammaPlan planning system. AVM regions were delineated independently by 2 physicians using either C-arm CBCT or MRA, resulting in 2 volumes: a CBCT volume (VCBCT) and an MRA volume (V{sub MRA}). SRS plans were generated based on the delineated regions. Results: The average volume of treatment targets delineated using C-arm CBCT and MRA were similar, 6.40 cm{sup 3} and 6.98 cm{sup 3}, respectively (P=.82). However, significant regions of nonoverlap existed. On average, the overlap of the MRA with the C-arm CBCT was only 52.8% of the total volume. In most cases, radiation plans based on V{sub MRA} did not provide adequate dose to the region identified on C-arm CBCT; the mean minimum dose to V{sub CBCT} was 29.5%, whereas the intended goal was 45% (P<.001). The mean volume of normal brain receiving 12 Gy or more in C-arm CBCT-based plans was not greater than in the MRA-based plans. Conclusions: Use of C-arm CBCT images significantly alters the delineated regions of AVMs for SRS planning, compared to that of MRA/MRI images. CT-based planning can be accomplished without increasing the dose to normal brain and may represent a more accurate definition of the nidus, increasing the chances for successful obliteration.« less
  • Twenty-one arteriovenous malformations were prospectively evaluated using magnetic resonance angiography, compare it to stereotactic angiography, employ magnetic resonance angiography in follow-up, and semiquanitfy flow. A correlative evaluation between flow and response to stereotactic radiosurgery was carried out. Phase contrast angiograms were obtained at flow velocities of 400, 200, 100, 60 and 20 cm/sec. The fractionated velocities provided images that selectively demonstrated the arterial and venous components of the arteriovenous malformations. Qualitative assessment of the velocity within the arteriovenous malformations and the presence of fistulae were also determined by multiple velocity images. In addition, 3-dimensional time-of-flight magnetic resonance angiograms were obtainedmore » to define the exact size and shape of the nidus. This technique also permitted evaluation of the nidus and feeding arteries for the the presence of low flow aneurysms. Correlation between the two imaging modalities was carried out by subjective and semiquantitative estimation of flow velocity and estimation of nidus size. The following velocity parameters were employed: fast, intermediate, slow, and none. Early analysis suggests that slower flowing arteriovenous malformations may obliterate faster after stereotactic radiosurgery an flow parameters should be employed to predict response. In conclusion, magnetic resonance angiography permits semiquantitative flow velocity assessment and may therefore be superior to stereotactic angiography. An additional advantage of magnetic resonance angiography is the generation of serial transverse images which can replace the conventional CT scan employed for stereotactic radiosurgery treatment planning. A single diagnostic test may therefore be used for diagnosis, radiosurgical treatment planning, follow-up, and treatment selection by identifying patients likely to respond early to radiosurgical management.« less
  • Purpose: Quantitative magnetic resonance imaging (MRI) of cranial lesions prior to stereotactic radiosurgery (SRS) may improve treatment planning and provide potential prognostic value. The practicality and logistics of acquiring advanced multiparametric MRI sequences to measure vascular and cellular properties of cerebral tumors are explored on a 1.0 Tesla MR Simulator. Methods: MR simulation was performed immediately following routine CT simulation on a 1T MR Simulator. MR sequences used were in the order they were performed: T2-Weighted Turbo Spin Echo (T2W-TSE), T2 FLAIR, Diffusion-weighted (DWI, b = 0, 800 to generate an apparent diffusion coefficient (ADC) map), 3D T1-Weighted Fast Fieldmore » Echo (T1W-FFE), Dynamic Contrast Enhanced (DCE) and Post Gadolinium Contrast Enhanced 3D T1W-FFE images. T1 pre-contrast values was generated by acquiring six different flip angles. The arterial input function was derived from arterial pixels in the perfusion images selected manually. The extended Tofts model was used to generate the permeability maps. Routine MRI scans took about 30 minutes to complete; the additional scans added 12 minutes. Results: To date, seven patients with cerebral tumors have been imaged and tumor physiology characterized. For example, on a glioblastoma patient, the volume contoured on T1 Gd images, ADC map and the pharmacokinetic map (Ktrans) were 1.9, 1.4, and 1.5 cc respectively with strong spatial correlation. The mean ADC value of the entire volume was 1141 μm2/s while the value in the white matter was 811 μm2/s. The mean value of Ktrans was 0.02 min-1 in the tumor volume and 0.00 in the normal white matter. Conclusion: Our initial results suggest that multiparametric MRI sequences may provide a more quantitative evaluation of vascular and tumor properties. Implementing functional imaging during MR-SIM may be particularly beneficial in assessing tumor extent, differentiating radiation necrosis from tumor recurrence, and establishing reliable bio-markers for treatment response evaluation. The Department of Radiation Oncology at Henry Ford Health System has research agreement with Varian Medical System and Philips Health Care.« less
  • Purpose: To determine how the omission of whole brain radiotherapy (WBRT) affects the neurocognitive function of patients with one to four brain metastases who have been treated with stereotactic radiosurgery (SRS). Methods and Materials: In a prospective randomized trial between WBRT+SRS and SRS alone for patients with one to four brain metastases, we assessed the neurocognitive function using the Mini-Mental State Examination (MMSE). Of the 132 enrolled patients, MMSE scores were available for 110. Results: In the baseline MMSE analyses, statistically significant differences were observed for total tumor volume, extent of tumor edema, age, and Karnofsky performance status. Of themore » 92 patients who underwent the follow-up MMSE, 39 had a baseline MMSE score of {<=}27 (17 in the WBRT+SRS group and 22 in the SRS-alone group). Improvements of {>=}3 points in the MMSEs of 9 WBRT+SRS patients and 11 SRS-alone patients (p = 0.85) were observed. Of the 82 patients with a baseline MMSE score of {>=}27 or whose baseline MMSE score was {<=}26 but had improved to {>=}27 after the initial brain treatment, the 12-, 24-, and 36-month actuarial free rate of the 3-point drop in the MMSE was 76.1%, 68.5%, and 14.7% in the WBRT+SRS group and 59.3%, 51.9%, and 51.9% in the SRS-alone group, respectively. The average duration until deterioration was 16.5 months in the WBRT+SRS group and 7.6 months in the SRS-alone group (p = 0.05). Conclusion: The results of the present study have revealed that, for most brain metastatic patients, control of the brain tumor is the most important factor for stabilizing neurocognitive function. However, the long-term adverse effects of WBRT on neurocognitive function might not be negligible.« less
  • Purpose: To compare the results of whole-brain radiotherapy plus stereotactic radiosurgery (WBRT+SRS) with those of surgery plus whole-brain radiotherapy and a boost to the metastatic site (OP+WBRT+boost) for patients with one or two brain metastases. Methods and Materials: Survival, intracerebral control, and local control of the treated metastases were retrospectively evaluated. To reduce the risk of selection bias, a matched-pair analysis was performed. The outcomes of 47 patients who received WBRT+SRS were compared with those of a second cohort of 47 patients who received OP+WBRT+boost. The two treatment groups were matched for the following potential prognostic factors: WBRT schedule, age,more » gender, performance status, tumor type, number of brain metastases, extracerebral metastases, recursive partitioning analysis class, and interval from tumor diagnosis to WBRT. Results: The 1-year survival rates were 65% after WBRT+SRS and 63% after OP+WBRT+boost (p = 0.19). The 1-year intracerebral control rates were 70% and 78% (p = 0.39), respectively. The 1-year local control rates were 84% and 83% (p = 0.87), respectively. On multivariate analyses, improved survival was significantly associated with better performance status (p = 0.009), no extracerebral metastases (p = 0.004), recursive partitioning analysis Class 1 (p = 0.004), and interval from tumor diagnosis to WBRT (p = 0.001). Intracerebral control was not significantly associated with any of the potential prognostic factors. Improved local control was significantly associated with no extracerebral metastases (p = 0.037). Conclusions: Treatment outcomes were not significantly different after WBRT+SRS compared with OP+WBRT+boost. However, WBRT+SRS is less invasive than OP+WBRT+boost and may be preferable for patients with one or two brain metastases. The results should be confirmed by randomized t0011ria.« less