Stereotactic radiosurgery for cerebellar arteriovenous malformations: an international multicenter study

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OBJECTIVE

Cerebellar arteriovenous malformations (AVMs) represent the majority of infratentorial AVMs and frequently have a hemorrhagic presentation. In this multicenter study, the authors review outcomes of cerebellar AVMs after stereotactic radiosurgery (SRS).

METHODS

Eight medical centers contributed data from 162 patients with cerebellar AVMs managed with SRS. Of these patients, 65% presented with hemorrhage. The median maximal nidus diameter was 2 cm. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent radiation-induced complications (RICs). Patients were followed clinically and radiographically, with a median follow-up of 60 months (range 7–325 months).

RESULTS

The overall actuarial rates of obliteration at 3, 5, 7, and 10 years were 38.3%, 74.2%, 81.4%, and 86.1%, respectively, after single-session SRS. Obliteration and a favorable outcome were more likely to be achieved in patients treated with a margin dose greater than 18 Gy (p < 0.001 for both), demonstrating significantly better rates (83.3% and 79%, respectively). The rate of latency preobliteration hemorrhage was 0.85%/year. Symptomatic post-SRS RICs developed in 4.5% of patients (n = 7). Predictors of a favorable outcome were a smaller nidus (p = 0.0001), no pre-SRS embolization (p = 0.003), no prior hemorrhage (p = 0.0001), a higher margin dose (p = 0.0001), and a higher maximal dose (p = 0.009). The Spetzler-Martin grade was not found to be predictive of outcome. The Virginia Radiosurgery AVM Scale score (p = 0.0001) and the Radiosurgery-Based AVM Scale score (p = 0.0001) were predictive of a favorable outcome.

CONCLUSIONS

SRS results in successful obliteration and a favorable outcome in the majority of patients with cerebellar AVMs. Most patients will require a nidus dose of higher than 18 Gy to achieve these goals. Radiosurgical and not microsurgical scales were predictive of clinical outcome after SRS.

ABBREVIATIONS AVM = arteriovenous malformation; GKRS = Gamma Knife radiosurgery; IGKRF = International Gamma Knife Research Foundation; RBAS = Radiosurgery-Based AVM Scale; RIC = radiosurgery-induced complication; SRS = stereotactic radiosurgery; VRAS = Virginia Radiosurgery AVM Scale.

Article Information

Correspondence Or Cohen-Inbar, Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, VA 22908. email: oc2f@virginia.edu.

INCLUDE WHEN CITING Published online September 30, 2016; DOI: 10.3171/2016.7.JNS161208.

Disclosures The authors report the following. Dr. Grills: direct stock ownership in and executive board of directors for Greater Michigan Gamma Knife. Dr. Lunsford: consultant for Elekta AB, Best Doctors, and Advance Medical; and direct stock ownership in Elekta AB.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case illustration. This 37-year-old woman presented with a posterior fossa hemorrhage from a large-nidus right cerebellar AVM (Spetzler-Martin Grade V, RBAS Score 2.34, VRAS Score 3). A and B: Axial T2-weighted images. C: Lateral angiogram. D and E: 3D MR angiographic reconstruction. The patient was initially treated conservatively (no microsurgery).

  • View in gallery

    Case illustration, continued. The patient underwent GKRS in 2007 and again in 2011 for a small remnant nidus. A–C: Axial T2-weighted MR image (A), lateral angiogram (B), and anteroposterior angiogram (C) obtained at the time of repeat radiosurgery (2011), showing a substantially smaller nidus retreated. D–F: Axial T2-weighted MR image (D), lateral angiogram (E), and anteroposterior angiogram (F) obtained 22 months after repeat radiosurgery, demonstrating complete AVM nidus obliteration. The patient suffered no latency hemorrhage, symptomatic RICs, or neurological deficits.

  • View in gallery

    Kaplan-Meier (KM) plot. Obliteration rate of the cerebellar AVMs each year with 95% confidence intervals. The actual number of patients at different time points is logged as well. Figure is available in color online only.

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