Stereotactic radiosurgery for postgeniculate visual pathway arteriovenous malformations

Bruce E. Pollock M.D.1, L. Dade Lunsford M.D.1, Douglas Kondziolka M.D., M.Sc., F.R.C.S.(C)1, David J. Bissonette P.A.C.1, and John C. Flickinger M.D.1
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  • 1 Departments of Neurological Surgery, Radiology, Radiation Oncology, and the Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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✓ Arteriovenous malformations (AVMs) that are located within the postgeniculate optic radiations or striate cortex are difficult to resect without creating postoperative visual defects. To reduce the risk of an AVM hemorrhage and to enhance the possibility of preserving visual function, the authors performed stereotactic radiosurgery in 34 patients with newly diagnosed or residual AVMs of the visual pathways. The mean AVM volume was 4.7 ml, and the average radiation dose to the AVM margin was 21 Gy. The median follow up was 47 months (range 16–83 months). Two (6%) of 34 patients had documented new visual field defects (central scotoma in one, and partial hemianopsia in one) after single-stage radiosurgery, but no patient developed a new permanent homonymous hemianopsia. Angiography was performed in all patients at a median of 26 months after radiosurgery: 22 (65%) had complete obliteration, 10 (29%) had a significant decrease in AVM volume, one (3%) had only a persistent early draining vein without residual nidus, and one (3%) had no change in the AVM. Thirteen (81%) of 16 patients with AVMs less of than 4 ml had complete obliteration. Five patients had second-stage stereotactic radiosurgery after angiography revealed a persistent AVM nidus; two patients eligible for follow-up angiography had complete obliteration, thereby increasing the overall series obliteration rate to 71%. The calculated annual risk of AVM bleeding (before radiographic evidence of obliteration) was 2.4%. No patient bled after angiographically confirmed obliteration.

In most patients stereotactic radiosurgery obliterates visual pathway AVMs and also preserves preoperative visual function. Multimodality management (embolization, microsurgery, or staged radiosurgery) enhances AVM obliteration and visual preservation rates.

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