Radiosurgery as a microsurgical adjunct: outcomes after microsurgical resection of intracranial arteriovenous malformations previously treated with stereotactic radiosurgery

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  • 1 Department of Neurosurgery and Stanford Stroke Center, Stanford University Medical Center, Stanford;
  • | 2 Quantitative Sciences Unit, Stanford Center for Biomedical Informatics Research (BMIR), Stanford;
  • | 3 Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda; and
  • | 4 Department of Radiology, Stanford University Medical Center, Stanford, California
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OBJECTIVE

Microsurgical resection of arteriovenous malformations (AVMs) can be aided by staged treatment consisting of stereotactic radiosurgery followed by resection in a delayed fashion. This approach is particularly useful for high Spetzler-Martin (SM) grade lesions because radiosurgery can reduce flow through the AVM, downgrade the SM rating, and induce histopathological changes that additively render the AVM more manageable for resection. The authors present their 28-year experience in managing AVMs with adjunctive radiosurgery followed by resection.

METHODS

The authors retrospectively reviewed records of patients treated for cerebral AVMs at their institution between January 1990 and August 2019. All patients who underwent stereotactic radiosurgery (with or without embolization), followed by resection, were included in the study. Of 1245 patients, 95 met the eligibility criteria. Univariate and multivariate regression analyses were performed to assess relationships between key variables and clinical outcomes.

RESULTS

The majority of lesions treated (53.9%) were high grade (SM grade IV–V), 31.5% were intermediate (SM grade III), and 16.6% were low grade (SM grade I–II). Hemorrhage was the initial presenting sign in half of all patients (49.5%). Complete resection was achieved among 84% of patients, whereas 16% had partial resection, the majority of whom received additional radiosurgery. Modified Rankin Scale (mRS) scores of 0–2 were achieved in 79.8% of patients, and 20.2% had poor (mRS scores 3–6) outcomes. Improved (44.8%) or stable (19%) mRS scores were observed among 63.8% of patients, whereas 36.2% had a decline in mRS scores. This includes 22 patients (23.4%) with AVM hemorrhage and 6 deaths (6.7%) outside the perioperative period but prior to AVM obliteration.

CONCLUSIONS

Stereotactic radiosurgery is a useful adjunct in the presurgical management of cerebral AVMs. Multimodal therapy allowed for high rates of AVM obliteration and acceptable morbidity rates, despite the predominance of high-grade lesions in this series of patients.

ABBREVIATIONS

AVM = arteriovenous malformation; DSA = digital subtraction angiography; LINAC = linear accelerator; mRS = modified Rankin Scale; SM = Spetzler-Martin.

Supplementary Materials

    • Supplementary Tables 1–3 (PDF 443 KB)

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Contributor Notes

Correspondence Gary K. Steinberg: Stanford University School of Medicine, Stanford, CA. gsteinberg@stanford.edu.

INCLUDE WHEN CITING Published online June 11, 2021; DOI: 10.3171/2020.9.JNS201538.

Disclosures Dr. Steinberg is a consultant for Peter Lazic US, NeuroSave, SanBio, Zeiss, and Surgical Theater.

M.B. and O.C. contributed equally to this work.

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