Object
Intracranial arteriovenous malformations (AVMs) are most commonly classified based on their Spetzler-Martin grades. Due to the composition of the Spetzler-Martin grading scale, Grade III AVMs ...are the most heterogeneous, comprising 4 distinct lesion subtypes. The management of this class of AVMs and the optimal treatment approach when intervention is indicated remain controversial. The authors report their experience with radiosurgery for the treatment of Grade III AVMs in a large cohort of patients.
Methods
All patients with Spetzler-Martin Grade III AVMs treated with radiosurgery at the University of Virginia over the 20-year span from 1989 to 2009 were identified. Patients who had less than 2 years of radiological follow-up and did not have evidence of complete obliteration during that period were excluded from the study, leaving 398 cases for analysis. The median patient age at treatment was 31 years. The most common presenting symptoms were hemorrhage (59%), seizure (20%), and headache (10%). The median AVM volume was 2.8 cm
3
, and the median prescription dose was 20 Gy. The median radiological and clinical follow-up intervals were 54 and 68 months, respectively. Univariate and multivariate Cox proportional hazards and logistic regression analysis were used to identify factors associated with obliteration, postradiosurgery radiation-induced changes (RIC), and favorable outcome.
Results
Complete AVM obliteration was observed in 69% of Grade III AVM cases at a median time of 46 months after radiosurgery. The actuarial obliteration rates at 3 and 5 years were 38% and 60%, respectively. The obliteration rate was higher in ruptured AVMs than in unruptured ones (p < 0.001). Additionally, the obliteration rate for Grade III AVMs with small size (< 3 cm diameter), deep venous drainage, and location in eloquent cortex was higher than for the other subtypes (p < 0.001). Preradiosurgery AVM rupture (p = 0.016), no preradiosurgery embolization (p = 0.003), increased prescription dose (p < 0.001), fewer isocenters (p = 0.006), and a single draining vein (p = 0.018) were independent predictors of obliteration. The annual risk of postradiosurgery hemorrhage during the latency period was 1.7%. Two patients (0.5%) died of hemorrhage during the radiosurgical latency period. The rates of symptomatic and permanent RIC were 12% and 4%, respectively. Absence of preradiosurgery AVM rupture (p < 0.001) and presence of a single draining vein (p < 0.001) were independent predictors of RIC. Favorable outcome was observed in 63% of patients. Independent predictors of favorable outcome were no preradiosurgery hemorrhage (p = 0.014), increased prescription dose (p < 0.001), fewer isocenters (p = 0.014), deep location (p = 0.014), single draining vein (p = 0.001), and lower Virginia radiosurgery AVM scale score (p = 0.016).
Conclusions
Radiosurgery for Spetzler-Martin Grade III AVMs yields relatively high rates of obliteration with a low rate of adverse procedural events. Small and ruptured lesions are more likely to become obliterated after radiosurgery than large and unruptured ones.
Background
Infection control is a major determinant of guided tissue regeneration (GTR). This study aims to develop an antibiotic‐loaded membrane to assist periodontal repair.
Methods
Poly(D,L‐lactic ...acid) (PDLLA) nanofibers encapsulating amoxicillin (PDLLA‐AMX) were fabricated using the electrospinning technique, and their structures, drug encapsulation efficiency, and release characteristics were assessed. The viability and behaviors of periodontal ligament (PDL) cells on nanofibers, and antibacterial capabilities of nanofibers were evaluated in vitro. Early therapeutic efficiency of the antibiotic‐loaded membranes was investigated in rats with ligature‐induced experimental periodontitis, and the outcomes were evaluated by gene expression, microcomputed tomography imaging, and histology within 7 days of membrane placement.
Results
AMX was successfully encapsulated in the PDLLA nanofibers and released in a sustained manner. After initial attachment was achieved, cells stretched out along with the directions of nanofibers. The viability and expression of migration‐associated gene of PDL cells were significantly improved, and the growth of Streptococcus sanguinis and Porphyromonas gingivalis was significantly reduced in the PDLLA‐AMX group compared with the controls. On PDLLA‐AMX‐treated sites, wound dehiscence and sulcular inflammation were reduced. Collagen fiber matrix deposition was accelerated with upregulated type I collagen and interleukin‐1β, and downregulated matrix metalloproteinase‐8, whereas periodontal bone level and the expressions of vascular endothelial growth factor and core‐binding factor subunit alpha‐1 were equivalent to conventional membrane treatment.
Conclusions
PDLLA‐AMX nanofibers inhibited bacterial growth and promoted the viability and mobility of PDL cells after initial cell attachment. Membranes with PDLLA‐AMX nanofibers reduced inflammation and accelerated periodontal repair at an early stage, providing good prospects for the further development of GTR membranes.
Stereotactic Radiosurgery for Acromegaly Lee, Cheng-Chia; Vance, Mary Lee; Xu, Zhiyuan ...
The journal of clinical endocrinology and metabolism,
2014-April, Letnik:
99, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Context:
The role of stereotactic radiosurgery (SRS) in acromegaly is being assessed.
Objective:
We evaluated the efficacy and safety of SRS for patients with acromegaly. Prognostic factors related ...to outcomes were also analyzed.
Design:
This was a retrospective study of patients treated with SRS at the University of Virginia; the data were collected from 1989 to 2012, with a median follow-up of 61.5 months.
Patients:
A total of 136 patients underwent SRS for acromegaly. Diagnosis of acromegaly was based on the combination of clinical features and biochemical assessment, including the serum GH level and age- and gender-matched serum IGF-1 level. All patients underwent a complete endocrine evaluation, neuroimaging study, and ophthalmic examinations before SRS.
Main Outcome Measures:
After withdrawal of GH- or IGF-1-altering medications, patients who had an oral glucose tolerance test GH of < 1.0 ng/mL or normal IGF-1 were considered in remission. Post-radiosurgical hypopituitarism was defined as a decrease in one or more hormones below normal.
Results:
With a median follow-up of 61.5 months, 65.4% of the patients achieved remission. The mean time to remission was 27.5 months. The actuarial remission rates at 2, 4, 6, and 8 years after radiosurgery were 31.7, 64.5, 73.4, and 82.6%, respectively. Favorable prognostic factors for remission included a higher margin radiation dose, higher maximum dose, and lower initial IGF-1 level. New pituitary hormone deficiency occurred in 43 patients (31.6%); two patients (1.5%) developed panhypopituitarism. Corresponding risk factors for new pituitary hormone deficiency were a margin dose > 25 Gy and tumor volume > 2.5 mL. Other complications included an adverse radiation effect in one patient, visual deterioration in four, and new oculomotor nerve palsy in one.
Conclusion:
SRS affords a reasonable rate of endocrine remission in patients with acromegaly and generally does so with a low rate of adverse effects.
The current gold standard for diagnosing arteriovenous malformation (AVM) and assessing its obliteration after stereotactic radiosurgery (SRS) is digital subtraction angiography (DSA). Recently, MRI ...and MR angiography (MRA) have become increasingly popular imaging modalities for the follow-up of patients with an AVM because of their convenient setup and noninvasiveness. In this study, the authors assessed the sensitivity and specificity of MRI/MRA in evaluating AVM nidus obliteration as assessed by DSA.
The authors study a consecutive series of 136 patients who underwent SRS between January 2000 and December 2012 and who underwent regular clinical examinations, several MRI studies, and at least 1 post-SRS DSA follow- up evaluation at the University of Virginia. The average follow-up time was 47.3 months (range 10.1-165.2 months). Two blinded observers were enrolled to interpret the results of MRI/MRA compared with those of DSA. The sensitivity, specificity, positive predictive value, and negative predictive value for the obliteration of AVM were reported.
On the basis of DSA, 73 patients (53.7%) achieved final angiographic obliteration in a median of 28.8 months. The sensitivity (the probability of finding obliteration on MRI/MRA among those for whom complete obliteration was shown on DSA) was 84.9% for one observer (Observer 1) and 76.7% for the other (Observer 2). The specificity was 88.9% and 95.2%, respectively. The false-negative interpretations were significantly related to the presence of draining veins, perinidal edema on T2-weighted images, and the interval between the MRI/MRA and DSA studies.
MRI/MRA predicted AVM obliteration after SRS in most patients and can be used in their follow-up. However, because the specificity of MRI/MRA is not perfect, DSA should still be performed to confirm AVM nidus obliteration after SRS.
The simulations and experiments for two 400 W low‐speed direct‐drive permanent magnet synchronous generators (PMSGs) installed in a Floating Kuroshio Turbine (FKT) were implemented. The towing tank ...experiments were carried out at National Taiwan University. A generator can start to harvest current energy at the rotation speed of 30 rpm (corresponding to the current flow rate of 0.36 m/s), and produce the rated power of 400 W at 150 rpm. The speed is very low compared with the published reports. The energy conversion efficiency of the FKT is up to 0.85. The results show that the generated direct current (DC) power is more than 800 W at a flow rate of 1.5 m/s. The power coefficient for the FKT is about 0.4. The energy loss at each stage and the power difference between the testing platform and the towing tank experiment were also analyzed. Moreover, the shape of the FKT is a new design. Compared with other structures, the proposed FKT can easily follow the direction of the ocean current and the depth of the FKT can be adjustable; when it doesn’t operate, it will float on the surface so that it is easy for maintenance.
STUDY DESIGN.An expert opinion.
OBJECTIVE.The aim of this study is to provide an overview of the surgical technique with an emphasis on complication avoidance techniques and to present a procedural ...checklist for the retroperitoneal transpsoas minimally invasive lateral approach.
SUMMARY OF BACKGROUND DATA.Although the minimally invasive lateral interbody fusion has gained popularity in the past decade, complication rate variability remains in the literature, driven by inconsistent adherence to technique, neuromonitoring, and complication avoidance techniques.
METHODS.The surgical and complication avoidance techniques for extreme lateral interbody fusion are presented in a stepwise fashion from the practice of an experienced lateral approach surgeon.
RESULTS.The technical description and procedural checklist cover preoperative assessment, operating room setup, patient positioning, surgical procedure, and postoperative evaluation.
CONCLUSION.A systematic approach through preoperative assessment, attention to surgical technique and intraoperative neuromonitoring, and a detailed postoperative evaluation are key to achieving the goal of lateral interbody fusion with minimization of procedural morbidity.Level of Evidence5
To evaluate the hemorrhage rates of cerebral arteriovenous malformations (AVM) and the risk factors of hemorrhage before and after Gamma Knife radiosurgery (GKS).
The annual hemorrhage rate was ...calculated as the number of hemorrhages divided by the patient-years at risk. Characteristics of patients and AVM related to hemorrhagic or nonhemorrhagic presentation were evaluated by logistic regression. Risk factors predicting AVM hemorrhage during the period from the diagnosis to GKS of AVM and during the latency period after radiosurgery were evaluated using Cox regression hazards model.
The annual hemorrhage rate before GKS was 2.0% assuming patients were at risk for hemorrhage since their birth. The hemorrhage rate calculated between the diagnosis and GKS of AVM was 6.6% and reduced to 2.5% after GKS until obliteration of the AVM. Although small and deep nidi and those with deep and single draining veins tended to present themselves with hemorrhage, only nidi with single draining veins and those ruptured before were more likely to bleed once the AVM had been diagnosed. These factors no longer predisposed the nidus to a rupture after radiosurgery and the only predicting factor for hemorrhage was a low radiosurgical prescription dose to the margin of nidus.
The AVM hemorrhage rate seems to reduce after GKS. After radiosurgery, none of the patients or nidus-related risk factors remained relevant to the occurrence of hemorrhage. The nidus treated with a high radiosurgical dose is less likely to bleed.
Epilepsy associated with arteriovenous malformations (AVMs) has an unclear course after stereotactic radiosurgery (SRS). Neither the risks of persistent seizures nor the requirement for postoperative ...antiepileptic drugs (AEDs) are well defined.
The authors performed a retrospective review of all patients with AVMs who underwent SRS at the University of Virginia Health System from 1989 to 2012. Seizure status was categorized according to a modified Engel classification. The effects of demographic, AVM-related, and SRS treatment factors on seizure outcomes were evaluated with logistic regression analysis. Changes in AED status were evaluated using McNemar's test.
Of the AVM patients with pre- or post-SRS seizures, 73 with pre-SRS epilepsy had evaluable data for subsequent analysis. The median patient age was 37 years (range 5-69 years), and the median follow-up period was 65.6 months (range 12-221 months). Sixty-five patients (89%) achieved seizure remission (Engel Class IA or IB outcome). Patients presenting with simple partial or secondarily generalized seizures were more likely to achieve Engel Class I outcome (p = 0.045). Twenty-one (33%) of 63 patients tapered off of pre-SRS AEDs. The incidence of freedom from AED therapy increased significantly after SRS (p < 0.001, McNemar's test). Of the Engel Class IA patients who continued AED therapy, 54% had patent AVM nidi, whereas only 19% continued AED therapy with complete AVM obliteration (p = 0.05).
Stereotactic radiosurgery is an effective treatment for long-term AVM-related epilepsy. Seizure-free patients on continued AED therapy were more likely to have residual AVM nidi. Simple partial or secondarily generalized seizure type were associated with better seizure outcomes following SRS.
High-performance GaN metal-oxide-semiconductor high-electron-mobility transistors (MOSHEMTs) using Al 2 O 3 gate dielectric deposited by atomic layer deposition (ALD) and damage-free neutral beam ...etch (NBE) gate recess process for millimeter-wave power applications are demonstrated. The high-quality ALD Al 2 O 3 reduces the gate leakage current of the device and the NBE method eliminates the plasma-induced defects in the nitride materials. The MOSHEMT device fabricated exhibits a high maximum drain current density (I DS,max ) of 1.65 A/mm and a high peak extrinsic transconductance (g m.ext ) of 653 mS/mm. The MOSHEMT device also demonstrates excellent RF performances, including f T /f MAX = 183/191 GHz, NF min = 2.56 dB with G AS = 5.61 dB at 54 GHz, and an output power density of 2.7 W/mm associated with a power-added efficiency of 20.9% and a linear power gain of 9.4 dB at 38 GHz. To the best of our knowledge, the noise performance at 54 GHz is the best reported so far for the AlGaN/GaN HEMTs.
Intracerebral hemorrhage is simultaneously the most frequent and most debilitating manifestation of intracranial arteriovenous malformations (AVM), but its impact on success and complications of ...radiosurgery has not been rigorously assessed. In this case-control study, we define the effect of prior hemorrhage on AVM radiosurgery outcomes.
From a prospective, institutional database of 1,400 AVM patients treated with Gamma Knife radiosurgery, unruptured and ruptured AVMs were matched in a 1:1 fashion, blinded to outcome, based on patient demographics, prior embolization (26.6% of each cohort), AVM size (mean volume of unruptured AVMs 3.7 cm(3) versus ruptured AVMs 3.5 cm(3), p = 0.195), Spetzler-Martin grade (Grade I 17.0%, Grade II 37.8%, Grade III 34.8%, Grade IV 10.4% for each cohort), and radiosurgical treatment parameters (mean prescription dose for unruptured AVMs 20.9 Gy versus ruptured AVMs 21.0 Gy, p = 0.837). There were 270 patients in each cohort. Matched statistical analyses were used to compare the baseline characteristics, obliteration rates, post-radiosurgery latency period hemorrhage risks, and incidences of radiation-induced changes (RIC) between the two cohorts.
The actuarial obliteration rates of the two cohorts were similar (unruptured AVMs: 38, 58, and 76% at 3, 5, 10 years, respectively; ruptured AVMs: 40, 60, and 73% at 3, 5, 10 years, respectively; p = 0.592). However, for embolized AVMs, complete obliteration was more likely to be achieved in unruptured lesions (unruptured AVMs: 25, 32, and 54% at 3, 5, 10 years, respectively; ruptured AVMs: 18, 27, and 42% at 3, 5, 10 years, respectively; p = 0.038). Prior AVM rupture resulted in a higher annual risk of post-radiosurgery latency period hemorrhage (ruptured AVMs 2.3% versus unruptured AVMs 1.1%, p = 0.025) but a lower rate of cumulative and symptomatic RIC (cumulative RIC: ruptured AVMs 30.4% versus unruptured AVMs 48.9%, p < 0.0001; symptomatic RIC: ruptured AVMs 7.0% versus unruptured AVMs 12.2%, p = 0.041, respectively). The rates of permanent RIC were similar between the unruptured (2.2%) and ruptured (1.9%) AVM cohorts (p = 0.761). The mean time interval to onset of RIC (unruptured AVMs 13.3 months versus ruptured AVMs 12.1 months, p = 0.783), and the mean duration of RIC (unruptured AVMs 22.0 months versus ruptured AVMs 21.7 months, p = 0.599) were not significantly different between the two cohorts.
Prior AVM rupture significantly alters the risk of latency period hemorrhage and RIC following radiosurgery. These effects should be taken into consideration with the multidisciplinary management of AVM patients. Radiosurgery does not significantly alter the natural history of the hemorrhage risks of unruptured and ruptured AVMs unless obliteration is achieved.
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