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Use of Cone-Beam Computed Tomography Angiography in Planning for Gamma Knife Radiosurgery for Arteriovenous Malformations: A Case Series and Early Report

Safain, Mina G. MD*; Rahal, Jason P. MD*; Raval, Ami MD*; Rivard, Mark J. PhD‡,§; Mignano, John E. MD, PhD‡,§; Wu, Julian K. MD*,§; Malek, Adel M. MD, PhD*,§

doi: 10.1227/NEU.0000000000000331
Research-Human-Clinical Studies

BACKGROUND: The effectiveness of Gamma Knife radiosurgery (GKR) for cerebral arteriovenous malformations (AVMs) is predicated on inclusion of the entire nidus while excluding normal tissue. As such, GKR may be limited by the resolution and accuracy of the imaging modality used in targeting.

OBJECTIVE: We present the first case series to demonstrate the feasibility of using ultrahigh-resolution C-arm cone-beam computed tomography angiography (CBCT-A) in AVM targeting.

METHODS: From June 2009 to June 2013, CBCT-A was used for targeting of all patients with AVMs treated with GKR at our institution. Patients underwent Leksell stereotactic head frame placement followed by catheter-based biplane 2-dimensional digital subtraction angiography, 3-dimensional rotational angiography, as well as CBCT-A. The CBCT-A dataset was used for stereotactic planning for GKR. Patients were followed at 1, 3, 6, and 12 months and then annually thereafter.

RESULTS: CBCT-A–based targeting was used in 22 consecutive patients. CBCT-A provided detailed spatial resolution and sensitivity of nidal angioarchitecture enabling treatment. The average radiation dose to the margin of the AVM nidus corresponding to the 50% isodose line was 15.6 Gy. No patient had treatment-associated hemorrhage. At early follow-up (mean, 16 months), 84% of patients had a decreasing or obliterated AVM nidus.

CONCLUSION: CBCT-A–guided radiosurgery is feasible and useful because it provides sufficient detailed resolution and sensitivity for imaging brain AVMs.

ABBREVIATIONS: AVM, arteriovenous malformation

CBCT-A, cone-beam computed tomography angiography

CTA, computed tomography angiography

DSA, digital subtraction angiography

GKR, Gamma Knife radiosurgery

MRA, magnetic resonance angiography

RA, rotational angiography

SRS, stereotactic radiosurgery

*Cerebrovascular and Endovascular Division, Department of Neurosurgery,

Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts;

§Boston Gamma Knife Center, Boston, Massachusetts

Correspondence: Adel M. Malek, MD, PhD, Department of Neurosurgery, Tufts Medical Center, 800 Washington Street, Proger 7, Boston, MA 02111. E-mail:

Received September 04, 2013

Accepted February 07, 2014

Copyright © by the Congress of Neurological Surgeons