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Radiosurgery Recommended for Unruptured Intracranial Arteriovenous Malformations

By MedImaging International staff writers
Posted on 11 Apr 2013

Researchers are recommending radiosurgery for treating unruptured arteriovenous malformations (AVMs) because the procedure has a reasonable benefit-to-risk profile. They base this recommendation on an assessment of clinical and radiographic outcomes in 444 patients treated with radiosurgery for unruptured AVMs at their institution.

This single-institution patient cohort were published online March 26, 2013, ahead of print, in the Journal of Neurosurgery, by investigators from the University of Virginia (UVA) Health System (Charlottesville, USA). Arteriovenous malformations are vascular anomalies in which arteries feed directly into veins, bypassing the capillary system.

Generally congenital, AVMs occur in approximately 1 in 100,000 persons and present equally in both sexes. Most people with AVMs in the brain live full lives with no knowledge of ever having the anomaly; sometimes the lesions are identified during workup for another disorder. Other patients experience symptoms such as headaches, seizures, and neurologic deficits. Patients who do experience symptoms often do so by the time they are in their 30s. Sometimes, AVMs rupture due to increased blood pressure and damage to the walls of the vessels involved. Past medical studies show the yearly risk of AVM hemorrhage to be 2%–4%.

In the present study, the UVA researchers reviewed a database of 1,204 cases of AVMs that were treated by radiosurgery with a Gamma Knife between 1989 and 2009. The researchers centered on 444 patients whose AVMs were unruptured at the time of radiosurgery and who participated in follow-up for at least two years (less if there was early proof that radiosurgery had obliterated the AVM). The patients’ mean age was 36.9 years; 11% of patients were younger than 18 years at the time of radiosurgery. The patient cohort was evenly split between the sexes. The investigators reported that the mean size of the AVM nidus was 4.2 cubic centimeters (approximately 2 cm in diameter). Nearly 14% of the AVMs were located deep within the brain. Twelve percent of patients presented with neurologic deficits, 28% with headaches, and 47% with seizures.

The median dose of radiation targeted to the edge of the AVM during radiosurgery was 20 Gray and the median maximum dose was 40 Gray. Sixty-four patients underwent radiosurgery as a repeat procedure. Univariate and multivariate Cox regression analyses were performed to identify the effects of various factors on AVM obliteration and determine risk factors associated with radiosurgery.

The researchers state that 62% of unruptured AVMs in this patient cohort were obliterated by radiosurgery. Their analyses revealed that a higher prescribed radiation dose, a single draining vein, radiation-induced alterations seen on the scans, a lower Spetzler-Martin AVM grade, and no earlier embolization procedure performed to treat the AVM were statistically significant positive predictors of AVM obliteration. After radiosurgery, the yearly hemorrhage rate was 1.6%, which is same as or may be slightly better than the 2%–4% estimated for unruptured AVMs left untreated. Once an AVM has been obliterated, however, there is no longer a risk of hemorrhage.

In comparison with the patients’ pre-radiosurgery neurologic symptoms, 7% of patients showed improvement, 7% were worse, and 86% were unchanged. The authors stated, “The risks associated with stereotactic radiosurgery were temporary; those risks that were permanent were typically not debilitating for the patient.”

Statistical analysis showed that worsening of clinical conditions was substantially more commonplace in patients who experienced bleeding after radiosurgery.

Patients typically present with unruptured AVMs when they are young. Without treatment, they must face many years at risk for hemorrhage, which can cause neurologic impairment and even death. The researchers believe that treatment of an AVM is indicated for these younger patients as well as for patients with large AVMs and those with worse radiosurgery-based AVM scores. Treatment of an AVM with the Gamma Knife appears necessary in most patients, even if the AVM has not previously ruptured. These researchers recommended radiosurgery as the means of treatment because of its “reasonable chance of obliteration of unruptured AVMs with relatively low rates of clinical and radiological complications.”

When asked for the take-home message of the study, the senior author, Dr. Jason Sheehan, said, “The essence of this study is that unruptured AVMs can rupture, and rupture has significant morbidity or even mortality. Gamma Knife radiosurgery yielded obliteration in the majority of unruptured AVMs. Obliterated AVMs do not rupture. The overall surgical risks of Gamma Knife radiosurgery in unruptured AVMs seem lower than those in the natural history of an AVM if left untreated, even if the AVM has not previously ruptured.”

The Gamma Knife technology was developed by Elekta (Stockholm, Sweden).

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58 (680.92346191406): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

59 (!!!!! 3057.9566955566): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

60 (235.08071899414): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

61 (!!!!! 1046.895980835): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

62 (154.97207641602): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

63 (!!!!! 4664.8979187012): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

64 (519.99092102051): SELECT fid FROM jos_deeppockets WHERE id=294745621 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294745621 AND published='1' LIMIT 1

65 (188.11225891113): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=211 ORDER BY `ordering`

66 (648.02169799805): select jos_twitters.link from jos_twitters where cat=10

67 (47.206878662109): select jos_facebook.link from jos_facebook where cat=10

68 (38.862228393555): select jos_google_plus.link from jos_google_plus where cat=10

69 (37.908554077148): select jos_linkedin.link from jos_linkedin where cat=10

70 (238.18016052246): SELECT fid FROM jos_deeppockets WHERE id=294745621 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294745621 AND published='1' LIMIT 1

71 (755.07164001465): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=211 ORDER BY `ordering`

72 (322.10350036621): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (229.1202545166): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

74 (48.87580871582): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

75 (65.088272094727): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (34.809112548828): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (!!!!! 6952.0473480225): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (121.8318939209): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (38.862228393555): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (34.809112548828): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

89 (79.154968261719): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (38.862228393555): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

91 (43.869018554688): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

92 (87.02278137207): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (41.007995605469): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (42.915344238281): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (36.954879760742): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (34.093856811523): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (35.04753112793): SELECT show_live FROM jos_com_show_setting LIMIT 1

106 (112.05673217773): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

107 (63.180923461914): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

108 (83.92333984375): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (159.97886657715): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

110 (118.01719665527): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

111 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

112 (74.863433837891): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (768.18466186523): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

114 (797.98698425293): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

115 (503.0632019043): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

116 (183.10546875): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

117 (80.108642578125): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

118 (87.976455688477): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

119 (69.141387939453): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

120 (83.208084106445): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

121 (73.909759521484): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

122 (76.055526733398): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

123 (67.949295043945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

124 (427.0076751709): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

125 (!!!!! 32634.973526001): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

126 (781.05926513672): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294745621 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294745621 AND type='deeppockets_item' AND published='1' LIMIT 1

127 (123.97766113281): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

128 (49.114227294922): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

129 (51.021575927734): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

130 (40.054321289062): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803337 LIMIT 1

131 (61.988830566406): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

132 (38.14697265625): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294803276 LIMIT 1

133 (36.954879760742): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

134 (36.954879760742): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets_archive AS dp WHERE dp.id = 294803276 LIMIT 1

135 (39.100646972656): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

136 (36.954879760742): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294802958 LIMIT 1

137 (723.12355041504): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (594.13909912109): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

139 (66.995620727539): SELECT name FROM jos_deeppockets WHERE id=211

140 (51.021575927734): SELECT name FROM jos_deeppockets WHERE id=211

141 (851.86958312988): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

142 (823.02093505859): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))211((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

143 (133.03756713867): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

144 (90.122222900391): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

145 (!!!!! 12264.966964722): TRUNCATE TABLE jos_trademed_module

146 (576.01928710938): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (453.94897460938): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294745621 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

148 (612.97416687012): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (130.17654418945): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

150 (422.95455932617): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

151 (77.009201049805): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

152 (!!!!! 1827.0015716553): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

153 (82.015991210938): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

154 (59.127807617188): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

155 (48.160552978516): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294745621 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294745621 AND type='deeppockets_item' AND published='1' LIMIT 1

156 (36.954879760742): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)

157 (48.87580871582): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=211 or channel_id is null)

158 (41.961669921875): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

159 (213.1462097168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

160 (86.069107055664): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294745621 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294745621 AND published='1' LIMIT 1

161 (67.949295043945): select jos_twitters.link from jos_twitters where cat=10

162 (44.107437133789): select jos_facebook.link from jos_facebook where cat=10

163 (46.968460083008): select jos_google_plus.link from jos_google_plus where cat=10

164 (46.968460083008): select jos_linkedin.link from jos_linkedin where cat=10

165 (467.06199645996): update jos_bannersmanager_banner set impmade=impmade+1 where id in(14615,14202,14203)

166 (!!!!! 1981.9736480713): insert into jos_banners_delta values (14615,'2025-08-19 09:17:31','216.73.216.0','view'),(14202,'2025-08-19 09:17:31','216.73.216.0','view'),(14203,'2025-08-19 09:17:31','216.73.216.0','view')

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