Definition of the key target volume in radiosurgical management of arteriovenous malformations: a new dynamic concept based on angiographic circulation time
Definition of the key target volume in radiosurgical management of arteriovenous malformations: a new dynamic concept based on angiographic circulation time
复制标题
DOI：
10.3171/jns/2008/109/12/s8
复制
发表时间：
2008-12-01
影响因子：
4.1
通讯作者：
De Anda, Salvador
中科院分区：
文献类型：
--
作者：
Del Valle, Ramiro;Zenteno, Marco;De Anda, Salvador
物体。世界各地的累积经验表明，脑动静脉畸形(AVM)的完全放射外科闭塞率从35%到90%不等。本研究的目的是提出一种通过动态定义关键靶区体积(KTV)来提高动静脉动静脉畸形消失率的策略。使用数字计数器测量逐帧循环时间的几个阶段，使用数字减影血管造影术对一系列患有动静脉畸形的患者进行评估。所有患者均采用动态测量计划来确定KTV，对应于血管阻力最小和静脉引流最早的分流量。所有患者都接受了基于导管的血管造影术，其中一个亚组通过超选择性插管进行了额外评估，其中另一个亚组接受了栓塞术。分流术还根据其血管构筑类型进行分类：瘘管型、丛状型或混合型。作者还应用了基于放射外科的分级系统(RBGS)来寻找与闭塞率的相关性。本组包括44例接受放射外科治疗的患者，所有患者均行全脑血管造影，包括动态测量计划。84%的患者接受了超选择性导尿术，50%的患者接受了栓塞术。栓塞组预处理量为120ml，单次治疗平均为8.5ml，中位数为6.95+/-4.56ml(平均+/-标准差)，平均KTV为15ml，前瞻性放射外科治疗平均KTV为28ml，边缘剂量为18~22GY，平均剂量为20GY。平均RBGS评分为1.70分。总的闭塞率为91%，其中重复放疗组4例，完全闭塞率为100%。44例患者中有2例永久性缺失，每组均为1例。动态定义KTV可能会增加闭塞率，即使在复杂的动静脉动静脉畸形中也是如此，从而允许治疗募集血管(假性结节)上的较小体积。通过使用这种技术，作者避免了双盲治疗，即神经外科医生不知道他或她正在照射的是哪种类型的病变，干预者不知道为什么和什么谎言或她正在栓塞。(DOI：10.3171/JNS/2008109/12/S8)
Object. The cumulative experience worldwide indicates complete radiosurgical obliteration rates of brain arteriovenous malformations (AVMs) ranging from 35 to 90%. The purpose of this study was to propose a strategy to increase the obliteration rate for AVMs through the dynamic definition of the key target volume (KTV).Methods. A prospective series of patients harboring an AVM was assessed using digital subtraction angiography in which a digital counter was used to measure the several stages of the frame-by-frame circulation time. All the patients were analyzed using dynamic measurement planning to define the KTV, corresponding to the volume of the shunt with the least vascular resistance and the earliest venous drainage. All patients underwent catheter-based angiography, a Subgroup was additionally assessed by means of a superselective catheterization, and among these a further subgroup received embolization. The shunts were also categorized according to their angioarchitectural type: fistulous, plexiform, or mixed. The authors applied the radiosurgery-based grading system (RBGS) as well to find a correlation with the obliteration rate.Results. This series includes 44 patients treated by radiosurgery, global angiography was performed for all patients, including dynamic measurement planning. Eighty-four percent of them underwent superselective catheterization, and 50% of the total Population underwent embolization. In the embolized arm of the Study, the pretreatment volume was up to 120 ml. In patients with a single treatment, the mean volume was 8.5 ml, and the median volume was 6.95 +/- 4.56 ml (mean +/- standard deviation), with a KTV of up to 15 ml. For prospectively staged radiosurgery, the mean KTV was 28 ml. The marginal radiation dose was 18-22 Gy, with a mean of dose 20 Gy. The mean RBGS score was 1.70. The overall obliteration rate was 91%, including the repeated radiosurgery group (4 patients), in which 100% showed complete obliteration. The overall permanent deficit was 2 of 44 patients, I in each group.Conclusions. Dynamic definition of the KTV might increase the obliteration rate, even in complex AVMs, allowing the treatment of smaller volumes off the recruitment vessels (pseudonidus). By using this technique, the authors avoided double-blind treatment, where the neurosurgeon does not know precisely which type of lesion he or she is irradiating and the interventionalist does not know why and what lie or she is embolizing. (DOI: 10.3171/JNS/2008/109/12/S8)