Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome

Restricted access

✓ Between May, 1988 and August, 1993, 158 patients with arteriovenous malformations (AVMs) were treated radiosurgically at the University of Florida. A mean dose of 1560 cGy was directed to the periphery of the lesions, which had a mean volume of 9 cc (0.5 to 45.3 cc). One hundred thirty-nine of these individuals were treated with one isocenter. The mean follow-up interval was 33 months with clinical information available on 153 of these patients. Patients were followed until magnetic resonance (MR) studies suggested complete AVM thrombosis. An arteriogram was then performed, if possible, to verify occlusion status. If arteriography revealed any persistent nidus at 36 months posttreatment, the residual nidus was re-treated.

Outcome categories of AVMs analyzed included the following possibilities: 1) angiographic cure; 2) angiographic failure; 3) re-treatment; 4) MR image suggested cure; 5) MR image suggested failure; 6) patient refused follow-up evaluation; 7) patient lost to follow-up study; or 8) patient deceased. The endpoints for success or failure of radiosurgery were as follows: angiographic occlusion (success), re-treatment (failure), and death due to AVM hemorrhage (failure). Fifty-six patients in this series reached one of the endpoints. Successful endpoints were seen in 91% of AVMs between 1 and 4 cc in volume, 100% of AVMs 4 to 10 cc in volume, and 79% of AVMs greater than 10 cc in volume.

The more traditional measure of radiosurgical success, percentage of angiograms showing complete obliteration, was obtained in 81% of AVMs between 1 and 4 cc in volume, 89% of AVMs between 4 and 10 cc in volume, and 69% of AVMs greater than 10 cc in volume. A detailed analysis of the relationship of all outcome categories to size is presented.

Article Information

Address reprint requests to: William A. Friedman, M.D., Department of Neurosurgery, Box 100265, JHMHC, University of Florida, Gainesville, Florida 32610.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Contrast-enhanced computerized tomography scans, axial (left), coronal (center), and sagittal (right) views of a woman presenting with seizures secondary to a left frontal arteriovenous malformation (AVM). A combination of four isocenters (28 mm, 28 mm, 28 mm, and 16 mm in diameter) were used to conform to the irregular contour of her lesion nidus. The total treatment volume was 21.7 cc. The isodose lines displayed are 70%, 35%, 14%, and 7% doses, as seen on axial (left), coronal (center), and sagittal (right) views. The vast majority of AVMs in this series were treated with a single isocenter.

  • View in gallery

    Graph displaying prescribed radiation dose (closed squares) to the periphery of every AVM versus that AVM's volume. Numbers displayed adjacent to data points indicate the number of patients treated at that particular volume and dose. In general, the larger the volume, the lower the dose that can be safely prescribed. The two patients with minor permanent neurological complications are indicated with bold initials. They were treated early in the series and received doses higher than those now used for lesions of similar volume. The three patients with transient radiation-induced complications are indicated with nonbold initials. They received doses that were safely used in other patients.

  • View in gallery

    Pretreatment angiograms, anteroposterior (A) and lateral, nidus outlined (B), of a 36-year-old woman who presented with a history consistent with subarachnoid hemorrhage and sensory seizures. Her arteriovenous malformation was 11.2 cc in volume and located in the left sylvian region. Because it was 28 mm in diameter and had no deep venous drainage, it was only a Spetzler—Martin Grade 2 lesion; however, because of location, surgery carried some risk of at least temporary neurological deficits. Posttreatment anteroposterior (C) and lateral (D) angiograms at 24-month review revealing complete thrombosis.

  • View in gallery

    Pretreatment angiograms, anteroposterior (A) and lateral, nidus outlined (B), of a 22-year-old woman with focal motor seizures. A 14-cc arteriovenous malformation was discovered in the right motor strip area. The lesion was treated with 1500 cGy to the 80% isodose line of a 30-mm collimator. She experienced several focal motor seizures in the first 24 hours after radiosurgery but otherwise remained well. Magnetic resonance images, anteroposterior (C) and lateral (D), obtained 3 years posttreatment suggesting a small amount of remaining nidus. After an angiogram confirmed persistent nidus, the stereotactic headring was applied, and she underwent repeat radiosurgery. The remaining nidus measured 2.9 cc in volume. It was treated with 1250 cGy to the 80% isodose line of an 18-mm collimator. The patient's status is now 8 months posttreatment.

References

  • 1.

    Betti OO: Treatment of arteriovenous malformations with the linear accelerator. Appl Neurophysiol 50:2621987Betti OO: Treatment of arteriovenous malformations with the linear accelerator. Appl Neurophysiol 50:262 1987

  • 2.

    Betti OOMunari CRosler R: Stereotactic radiosurgery with the linear accelerator: treatment of arteriovenous malformations. Neurosurgery 24:3113211989Betti OO Munari C Rosler R: Stereotactic radiosurgery with the linear accelerator: treatment of arteriovenous malformations. Neurosurgery 24:311–321 1989

  • 3.

    Blatt DRFriedman WABova FJ: Modifications based on computed tomographic imaging in planning the radiosurgical treatment of arteriovenous malformations. Neurosurgery 33:5885961993Blatt DR Friedman WA Bova FJ: Modifications based on computed tomographic imaging in planning the radiosurgical treatment of arteriovenous malformations. Neurosurgery 33:588–596 1993

  • 4.

    Bova FJ: Radiation physics. Neurosurg Clin North Am 1:9099311990Bova FJ: Radiation physics. Neurosurg Clin North Am 1:909–931 1990

  • 5.

    Bova FJ: Stereotactic angiography: an inadequate database for radiosurgery? Int J Radiat Oncol Biol Phys 20:8918951991Bova FJ: Stereotactic angiography: an inadequate database for radiosurgery? Int J Radiat Oncol Biol Phys 20:891–895 1991

  • 6.

    Colombo FBenedetti APozza Fet al: External stereotactic irradiation by linear accelerator. Neurosurgery 16:1541601985Colombo F Benedetti A Pozza F et al: External stereotactic irradiation by linear accelerator. Neurosurgery 16:154–160 1985

  • 7.

    Colombo FBenedetti APozza Fet al: Linear accelerator radiosurgery of cerebral arteriovenous malformations. Neurosurgery 24:8338401989Colombo F Benedetti A Pozza F et al: Linear accelerator radiosurgery of cerebral arteriovenous malformations. Neurosurgery 24:833–840 1989

  • 8.

    Colombo FBenedetti APozza Fet al: Linear accelerator radiosurgery of three-dimensional irregular targets. Stereotact Funct Neurosurg 54–55:5415461990Colombo F Benedetti A Pozza F et al: Linear accelerator radiosurgery of three-dimensional irregular targets. Stereotact Funct Neurosurg 54–55:541–546 1990

  • 9.

    Flickinger JC: An integrated logistic formula for prediction of complications from radiosurgery. Int J Radiat Oncol Biol Phys 17:8798851989Flickinger JC: An integrated logistic formula for prediction of complications from radiosurgery. Int J Radiat Oncol Biol Phys 17:879–885 1989

  • 10.

    Flickinger JCSchell MCLarson DA: Estimation of complications for linear accelerator radiosurgery with the integrated logistic formula. Int J Radiat Oncol Biol Phys 19:1431481990Flickinger JC Schell MC Larson DA: Estimation of complications for linear accelerator radiosurgery with the integrated logistic formula. Int J Radiat Oncol Biol Phys 19:143–148 1990

  • 11.

    Francel PCSteiner LSteiner Met al: Repeat radiosurgical treatment in arteriovenous malformations following unsatisfactory result of initial single high-dose radiation. J Neurosurg 74:352A1991 (Abstract)Francel PC Steiner L Steiner M et al: Repeat radiosurgical treatment in arteriovenous malformations following unsatisfactory result of initial single high-dose radiation. J Neurosurg 74:352A 1991 (Abstract)

  • 12.

    Friedman WA: LINAC radiosurgery in Friedman WA (ed): Neurosurgical Clinics of North America: Stereotactic Neurosurgery. Philadelphia: WB Saunders1990 pp 9911008Friedman WA: LINAC radiosurgery in Friedman WA (ed): Neurosurgical Clinics of North America: Stereotactic Neurosurgery. Philadelphia: WB Saunders 1990 pp 991–1008

  • 13.

    Friedman WABova FJ: Linear accelerator radiosurgery for arteriovenous malformations. J Neurosurg 77:8328411992Friedman WA Bova FJ: Linear accelerator radiosurgery for arteriovenous malformations. J Neurosurg 77:832–841 1992

  • 14.

    Friedman WABova FJ: Stereotactic radiosurgery. Contemp Neurosurg 11(12):171989Friedman WA Bova FJ: Stereotactic radiosurgery. Contemp Neurosurg 11 (12):1–7 1989

  • 15.

    Friedman WABova FJ: The University of Florida radiosurgery system. Surg Neurol 32:3343421989Friedman WA Bova FJ: The University of Florida radiosurgery system. Surg Neurol 32:334–342 1989

  • 16.

    Friedman WABova FJSpiegelmann R: Linear accelerator radiosurgery at the University of Florida. Neurosurg Clin North Am 3:1411661992Friedman WA Bova FJ Spiegelmann R: Linear accelerator radiosurgery at the University of Florida. Neurosurg Clin North Am 3:141–166 1992

  • 17.

    Guo WYNordell BKarlsson Bet al: Target delineation in radiosurgery for cerebral arteriovenous malformations. Assessment of the value of stereotaxic MR imaging. Acta Radiol 34:4574631993Guo WY Nordell B Karlsson B et al: Target delineation in radiosurgery for cerebral arteriovenous malformations. Assessment of the value of stereotaxic MR imaging. Acta Radiol 34:457–463 1993

  • 18.

    Hosobuchi YFabricant JILyman JT: Stereotactic heavy-particle irradiation of intracranial arteriovenous malformations. Appl Neurophysiol 50:2482521987Hosobuchi Y Fabricant JI Lyman JT: Stereotactic heavy-particle irradiation of intracranial arteriovenous malformations. Appl Neurophysiol 50:248–252 1987

  • 19.

    Kemeny AADias PSForster DM: Results of stereotactic radiosurgery of arteriovenous malformations: an analysis of 52 cases. J Neurol Neurosurg Psychiatry 52:5545581989Kemeny AA Dias PS Forster DM: Results of stereotactic radiosurgery of arteriovenous malformations: an analysis of 52 cases. J Neurol Neurosurg Psychiatry 52:554–558 1989

  • 20.

    Kjellberg RNAbe M: Stereotactic Bragg peak proton beam therapy in Lunsford LD (ed): Modern Stereotactic Neurosurgery. Boston: Martinus Nijhoff1988 pp 463470Kjellberg RN Abe M: Stereotactic Bragg peak proton beam therapy in Lunsford LD (ed): Modern Stereotactic Neurosurgery. Boston: Martinus Nijhoff 1988 pp 463–470

  • 21.

    Kjellberg RNHanamura TDavis KRet al: Bragg-peak proton-beam therapy for arteriovenous malformations of the brain. N Engl J Med 309:2692741983Kjellberg RN Hanamura T Davis KR et al: Bragg-peak proton-beam therapy for arteriovenous malformations of the brain. N Engl J Med 309:269–274 1983

  • 22.

    Lindquist CSteiner L: Stereotactic radiosurgical treatment of malformations of the brain in Lunsford LD (ed): Modern Stereotactic Neurosurgery. Boston: Martinus Nijhoff1988 pp 491506Lindquist C Steiner L: Stereotactic radiosurgical treatment of malformations of the brain in Lunsford LD (ed): Modern Stereotactic Neurosurgery. Boston: Martinus Nijhoff 1988 pp 491–506

  • 23.

    Loeffler JSAlexander E IIISiddon RLet al: Stereotactic radiosurgery for intracranial arteriovenous malformations using a standard linear accelerator. Int J Radiat Oncol Biol Phys 17:6736771989Loeffler JS Alexander E III Siddon RL et al: Stereotactic radiosurgery for intracranial arteriovenous malformations using a standard linear accelerator. Int J Radiat Oncol Biol Phys 17:673–677 1989

  • 24.

    Loeffler JSSiddon RLWen PYet al: Stereotactic radiosurgery of the brain using a standard linear accelerator: a study of early and late effects. Radiother Oncol 17:3113211990Loeffler JS Siddon RL Wen PY et al: Stereotactic radiosurgery of the brain using a standard linear accelerator: a study of early and late effects. Radiother Oncol 17:311–321 1990

  • 25.

    Lunsford LDKondziolka DFlickinger JCet al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:5125241991Lunsford LD Kondziolka D Flickinger JC et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512–524 1991

  • 26.

    Marks LBSpencer DP: The influence of volume on the tolerance of the brain to radiosurgery. J Neurosurg 75:1771801991Marks LB Spencer DP: The influence of volume on the tolerance of the brain to radiosurgery. J Neurosurg 75:177–180 1991

  • 27.

    Mehta CRPatel NRGray R: Computing an exact confidence interval for the common odds ratio in several 2 × 2 contingency tables. J Am Stat Assoc 80:9699731986Mehta CR Patel NR Gray R: Computing an exact confidence interval for the common odds ratio in several 2 × 2 contingency tables. J Am Stat Assoc 80:969–973 1986

  • 28.

    Ogilvy CS: Radiation therapy for arteriovenous malformations: a review. Neurosurgery 26:7257351990Ogilvy CS: Radiation therapy for arteriovenous malformations: a review. Neurosurgery 26:725–735 1990

  • 29.

    Phillips MHKessler MChuang FYSet al: Image correlation of MRI and CT in treatment planning for radiosurgery of intracranial vascular malformations. Int J Radiat Oncol Biol Phys 20:8818891991Phillips MH Kessler M Chuang FYS et al: Image correlation of MRI and CT in treatment planning for radiosurgery of intracranial vascular malformations. Int J Radiat Oncol Biol Phys 20:881–889 1991

  • 30.

    Quisling RGPeters KRFriedman WAet al: Persistent nidus blood flow in cerebral arteriovenous malformation after stereotactic radiosurgery: MR imaging assessment. Radiology 180:7857911991Quisling RG Peters KR Friedman WA et al: Persistent nidus blood flow in cerebral arteriovenous malformation after stereotactic radiosurgery: MR imaging assessment. Radiology 180:785–791 1991

  • 31.

    Souhami LOlivier APodgorsak EBet al: Radiosurgery of cerebral arteriovenous malformations with the dynamic stereotactic irradiation. Int J Radiat Oncol Biol Phys 19:7757821990Souhami L Olivier A Podgorsak EB et al: Radiosurgery of cerebral arteriovenous malformations with the dynamic stereotactic irradiation. Int J Radiat Oncol Biol Phys 19:775–782 1990

  • 32.

    Spetzler RFMartin NA: A proposed grading system of arteriovenous malformations. J Neurosurg 65:4764831985Spetzler RF Martin NA: A proposed grading system of arteriovenous malformations. J Neurosurg 65:476–483 1985

  • 33.

    Spiegelmann RFriedman WABova FJ: Limitations of angiographic target localization in planning radiosurgical treatment. Neurosurgery 30:6196241992Spiegelmann R Friedman WA Bova FJ: Limitations of angiographic target localization in planning radiosurgical treatment. Neurosurgery 30:619–624 1992

  • 34.

    Steinberg GKFabricant JIMarks MPet al: Stereotactic heavy-charged particle Bragg—peak radiation for intracranial arteriovenous malformations. N Engl J Med 323:961011990Steinberg GK Fabricant JI Marks MP et al: Stereotactic heavy-charged particle Bragg—peak radiation for intracranial arteriovenous malformations. N Engl J Med 323:96–101 1990

  • 35.

    Steiner L: Radiosurgery in cerebral arteriovenous malformations in Fein JMFlamm ES (eds): Cerebrovascular Surgery. New York: Springer-Verlag1985 Vol 4 pp 11611215Steiner L: Radiosurgery in cerebral arteriovenous malformations in Fein JM Flamm ES (eds): Cerebrovascular Surgery. New York: Springer-Verlag 1985 Vol 4 pp 1161–1215

  • 36.

    Steiner L: Treatment of arteriovenous malformations by radiosurgery in Wilson CBStein BM (eds): Intracranial Arteriovenous Malformations. Baltimore: Williams & Wilkins1984 pp 295313Steiner L: Treatment of arteriovenous malformations by radiosurgery in Wilson CB Stein BM (eds): Intracranial Arteriovenous Malformations. Baltimore: Williams & Wilkins 1984 pp 295–313

  • 37.

    Steiner LLeksell LForster DMet al: Stereotactic radiosurgery in intracranial arteriovenous malformations. Acta Neurochir Suppl 21:1952091974Steiner L Leksell L Forster DM et al: Stereotactic radiosurgery in intracranial arteriovenous malformations. Acta Neurochir Suppl 21:195–209 1974

  • 38.

    Steiner LLeksell LGreitz Tet al: Stereotaxic radiosurgery for cerebral arteriovenous malformations. Report of a case. Acta Chir Scand 138:4594641972Steiner L Leksell L Greitz T et al: Stereotaxic radiosurgery for cerebral arteriovenous malformations. Report of a case. Acta Chir Scand 138:459–464 1972

  • 39.

    Steiner LLindquist CAdler JRet al: Clinical outcome of radiosurgery for cerebral arteriovenous malformations. J Neurosurg 77:181992Steiner L Lindquist C Adler JR et al: Clinical outcome of radiosurgery for cerebral arteriovenous malformations. J Neurosurg 77:1–8 1992

  • 40.

    Yamamoto MJimbo MIde Met al: Long-term follow-up of radiosurgically treated arteriovenous malformations in children: report of nine cases. Surg Neurol 38:951001992Yamamoto M Jimbo M Ide M et al: Long-term follow-up of radiosurgically treated arteriovenous malformations in children: report of nine cases. Surg Neurol 38:95–100 1992

  • 41.

    Yamamoto MJimbo MKobayashi Met al: Long-term results of radiosurgery for arteriovenous malformation: neurodiagnostic imaging and histological studies of angiographically confirmed nidus obliteration. Surg Neurol 37:2192301992Yamamoto M Jimbo M Kobayashi M et al: Long-term results of radiosurgery for arteriovenous malformation: neurodiagnostic imaging and histological studies of angiographically confirmed nidus obliteration. Surg Neurol 37:219–230 1992

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 64 64 7
Full Text Views 131 131 3
PDF Downloads 91 91 1
EPUB Downloads 0 0 0

PubMed

Google Scholar