Gamma Knife surgery for arteriovenous malformations within or adjacent to the ventricles

Clinical article

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Object

The outcomes of stereotactic radiosurgery for arteriovenous malformations (AVMs) within or adjacent to the ventricular system are largely unknown. This study assessed the long-term outcomes and hemorrhage risks for patients with AVMs within this region who underwent Gamma Knife surgery (GKS) at the University of Pittsburgh.

Methods

The authors retrospectively identified 188 patients with ventricular-region AVMs who underwent a single-stage GKS procedure during a 22-year interval. The median patient age was 32 years (range 3–80 years), the median target volume was 4.6 cm3 (range 0.1–22 cm3), and the median marginal dose was 20 Gy (range 13–27 Gy).

Results

Arteriovenous malformation obliteration was confirmed by MRI or angiography in 89 patients during a median follow-up of 65 months (range 2–265 months). The actuarial rates of total obliteration were 32% at 3 years, 55% at 4 years, 60% at 5 years, and 64% at 10 years. Higher rates of AVM obliteration were obtained in the 26 patients with intraventricular AVMs. Twenty-five patients (13%) sustained a hemorrhage during the initial latency interval after GKS, indicating an annual hemorrhage rate of 3.4% prior to AVM obliteration. No patient experienced a hemorrhage after AVM obliteration was confirmed by imaging. Permanent neurological deficits due to adverse radiation effects developed in 7 patients (4%).

Conclusions

Although patients in this study demonstrated an elevated hemorrhage risk that remained until complete obliteration, GKS still proved to be a generally safe and effective treatment for patients with these high-risk intraventricular and periventriclar AVMs.

Abbreviations used in this paper:AVM = arteriovenous malformation; GKS = Gamma Knife surgery.

Article Information

Address correspondence to: Hideyuki Kano, M.D., Ph.D., Department of Neurological Surgery, University of Pittsburgh, Ste. B-400, UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213. email: kanoh@upmc.edu.

Please include this information when citing this paper: published online May 30, 2014; DOI: 10.3171/2014.4.JNS131943.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Kaplan-Meier curve for total AVM obliteration based on MRI and angiography combined. Patients remaining in the analysis are indicated at 3 and 5 years.

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    Obliteration rate versus AVM volume, separated at ≤ 4 cm3 (71 patients; solid line) or > 4 cm3 (117 patients; dotted line). At 3 years, 34 patients remained in the ≤ 4 cm3 analysis and 79 patients in the > 4 cm3 analysis.

  • View in gallery

    Comparison of AVM obliteration on MRI in the ≥ 20 Gy margin dose group (137 patients; solid line) and the < 20 Gy margin dose group (51 patients; dotted line). At 3 years, 79 patients with a dose ≥ 20 Gy remained in the analysis while 24 patients in the < 20 Gy group remained.

  • View in gallery

    Comparison of AVM obliteration on MRI between periventricular (163 patients; solid line) and intraventricular (25 patients; dotted line) AVMs. At 3 years, 93 patients remained in the analysis from the periventricular group and 9 patients from the intraventricular group remained.

  • View in gallery

    Bleeding rate during the latency period prior to AVM obliteration. At 5 years, 123 patients remained in the analysis, and at 10 years, 43 patients remained.

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