Stereotactic radiosurgery for brainstem arteriovenous malformations: factors affecting outcome

View More View Less
  • 1 Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object. Management options for arteriovenous malformations (AVMs) of the brainstem are limited. The long-term results of stereotactic radiosurgery for these disease entities are poorly understood. In this report the authors reviewed both neurological and radiological outcomes following stereotactic radiosurgery for brainstem AVMs over 15 years of experience.

Methods. Fifty patients with brainstem AVMs underwent gamma knife surgery between 1987 and 2002. There were 29 male and 21 female patients with an age range of 7 to 79 years (median 35 years). Anatomical locations of these AVMs included the midbrain (39 lesions), pons (20 lesions), and medulla oblongata (three lesions). The radiation dose applied to the margin of the AVM varied from 12 to 26 Gy (median 20 Gy). Forty-five patients were followed up from 5 to 176 months (mean 72 months). The angiographically confirmed actuarial obliteration rate was 66% at the final follow-up examination. Two patients experienced a hemorrhage before obliteration. The annual hemorrhage rate was 1.7% for the first 3 years after radiosurgery and 0% thereafter. Patients who had received irradiation at two or fewer isocenters had higher obliteration rates (80% compared with 44% for > two isocenters, p = 0.006), and this was related to a more spherical nidus shape. The rate of persistent neurological complications in patients treated using magnetic resonance imaging—based dose planning after 1993 was 7%, compared with 20% in patients treated before 1993. An older patient age, a lesion located in the tectum, and a higher radiosurgery-based score were significantly associated with greater neurological complications.

Conclusions. Stereotactic radiosurgery provided complete obliteration of AVMs in two thirds of the patients with a low risk of latency-interval hemorrhage. Better three-dimensional imaging studies and conformal dose planning reduced the risk of adverse radiation effects. Younger patients harboring more spherical AVMs that did not involve the tectal plate had the best outcomes.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Douglas Kondziolka, M.D., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: kondziolkads@msx.upmc.edu.
  • 1.

    Bhatnagar A, , Flickinger JC, & Kondziolka D, et al: An analysis of the effects of smoking and other cardiovascular risk factors on obliteration rates after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 51:969973, 2001 Bhatnagar A, Flickinger JC, Kondziolka D, et al: An analysis of the effects of smoking and other cardiovascular risk factors on obliteration rates after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 51:969–973, 2001

    • Search Google Scholar
    • Export Citation
  • 2.

    Chang JH, , Chang JW, & Park YG, et al: Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 93 (Suppl 3):96101, 2000 Chang JH, Chang JW, Park YG, et al: Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 93 (Suppl 3):96–101, 2000

    • Search Google Scholar
    • Export Citation
  • 3.

    Drake CG, , Friedman AH, & Peerless SJ: Posterior fossa arteriovenous malformations. J Neurosurg 64:110, 1986 Drake CG, Friedman AH, Peerless SJ: Posterior fossa arteriovenous malformations. J Neurosurg 64:1–10, 1986

    • Search Google Scholar
    • Export Citation
  • 4.

    Duma CM, , Lunsford LD, & Kondziolka D, et al: Radiosurgery for vascular malformations of the brain stem. Acta Neurochir Suppl 58:9297, 1993 Duma CM, Lunsford LD, Kondziolka D, et al: Radiosurgery for vascular malformations of the brain stem. Acta Neurochir Suppl 58:92–97, 1993

    • Search Google Scholar
    • Export Citation
  • 5.

    Firlik AD, , Levy EI, & Kondziolka D, et al: Staged volume radiosurgery followed by microsurgical resection: a novel treatment for giant cerebral arteriovenous malformations: technical case report. Neurosurgery 43:12231228, 1998 Firlik AD, Levy EI, Kondziolka D, et al: Staged volume radiosurgery followed by microsurgical resection: a novel treatment for giant cerebral arteriovenous malformations: technical case report. Neurosurgery 43:1223–1228, 1998

    • Search Google Scholar
    • Export Citation
  • 6.

    Flickinger JC: An integrated logistic formula for prediction of complications from radiosurgery. Int J Radiat Oncol Biol Phys 17:879885, 1989 Flickinger JC: An integrated logistic formula for prediction of complications from radiosurgery. Int J Radiat Oncol Biol Phys 17:879–885, 1989

    • Search Google Scholar
    • Export Citation
  • 7.

    Flickinger JC, , Kondziolka D, & Lunsford LD, et al: Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Arteriovenous Malformation Radiosurgery Study Group. Int J Radiat Oncol Biol Phys 46:11431148, 2000 Flickinger JC, Kondziolka D, Lunsford LD, et al: Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Arteriovenous Malformation Radiosurgery Study Group. Int J Radiat Oncol Biol Phys 46:1143–1148, 2000

    • Search Google Scholar
    • Export Citation
  • 8.

    Flickinger JC, , Kondziolka D, & Maitz AH, et al: An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol 63:347354, 2002 Flickinger JC, Kondziolka D, Maitz AH, et al: An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol 63:347–354, 2002

    • Search Google Scholar
    • Export Citation
  • 9.

    Flickinger JC, , Lunsford LD, & Kondziolka D, et al: Radiosurgery and brain tolerance: an analysis of neurodiagnostic imaging changes after gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 23:1926, 1992 Flickinger JC, Lunsford LD, Kondziolka D, et al: Radiosurgery and brain tolerance: an analysis of neurodiagnostic imaging changes after gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 23:19–26, 1992

    • Search Google Scholar
    • Export Citation
  • 10.

    Graf CJ, , Perret GE, & Torner JC: Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58:331337, 1983 Graf CJ, Perret GE, Torner JC: Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58:331–337, 1983

    • Search Google Scholar
    • Export Citation
  • 11.

    Hadjipanayis CG, , Levy EI, & Niranjan A, et al: Stereotactic radiosurgery for motor cortex region arteriovenous malformations. Neurosurgery 48:7077, 2001 Hadjipanayis CG, Levy EI, Niranjan A, et al: Stereotactic radiosurgery for motor cortex region arteriovenous malformations. Neurosurgery 48:70–77, 2001

    • Search Google Scholar
    • Export Citation
  • 12.

    Heros RC, , Korosue K, & Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570578, 1990 Heros RC, Korosue K, Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570–578, 1990

    • Search Google Scholar
    • Export Citation
  • 13.

    Karlsson B, , Lax I, & Soderman M: Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 49:10451051, 2001 Karlsson B, Lax I, Soderman M: Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 49:1045–1051, 2001

    • Search Google Scholar
    • Export Citation
  • 14.

    Karlsson B, , Lax I, & Soderman M, et al: Prediction of results following Gamma Knife surgery for brain stem and other centrally located arteriovenous malformations: relation to natural course. Stereotact Funct Neurosurg 66 (Suppl 1):260268, 1996 Karlsson B, Lax I, Soderman M, et al: Prediction of results following Gamma Knife surgery for brain stem and other centrally located arteriovenous malformations: relation to natural course. Stereotact Funct Neurosurg 66 (Suppl 1):260–268, 1996

    • Search Google Scholar
    • Export Citation
  • 15.

    Karlsson B, , Lindquist C, & Steiner L: Prediction of obliteration after gamma knife surgery for cerebral arteriovenous malformations. Neurosurgery 40:425431, 1997 Karlsson B, Lindquist C, Steiner L: Prediction of obliteration after gamma knife surgery for cerebral arteriovenous malformations. Neurosurgery 40:425–431, 1997

    • Search Google Scholar
    • Export Citation
  • 16.

    Kurita H, , Kawamoto S, & Sasaki T, et al: Results of radiosurgery for brain stem arteriovenous malformations. J Neurol Neurosurg Psychiatry 68:563570, 2000 Kurita H, Kawamoto S, Sasaki T, et al: Results of radiosurgery for brain stem arteriovenous malformations. J Neurol Neurosurg Psychiatry 68:563–570, 2000

    • Search Google Scholar
    • Export Citation
  • 17.

    Lawton MT, , Hamilton MG, & Spetzler RF: Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery 37:2936, 1995 Lawton MT, Hamilton MG, Spetzler RF: Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery 37:29–36, 1995

    • Search Google Scholar
    • Export Citation
  • 18.

    Lunsford LD, , Kondziolka D, & Flickinger JC, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512524, 1991 Lunsford LD, Kondziolka D, Flickinger JC, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512–524, 1991

    • Search Google Scholar
    • Export Citation
  • 19.

    Massager N, , Regis J, & Kondziolka D, et al: Gamma knife radiosurgery for brainstem arteriovenous malformations: preliminary results. J Neurosurg 93 (Suppl 3):102103, 2000 Massager N, Regis J, Kondziolka D, et al: Gamma knife radiosurgery for brainstem arteriovenous malformations: preliminary results. J Neurosurg 93 (Suppl 3):102–103, 2000

    • Search Google Scholar
    • Export Citation
  • 20.

    Newman NM: Nystagmus and related ocular movements, in Wilkins RH, & Rengachary SS (eds): Neurosurgery, ed 2. New York: McGraw-Hill, 1996, pp 117121 Newman NM: Nystagmus and related ocular movements, in Wilkins RH, Rengachary SS (eds): Neurosurgery, ed 2. New York: McGraw-Hill, 1996, pp 117–121

    • Search Google Scholar
    • Export Citation
  • 21.

    Nussbaum ES, , Heros RC, & Camarata PJ: Surgical treatment of intracranial arteriovenous malformations with an analysis of cost-effectiveness. Clin Neurosurg 42:348369, 1995 Nussbaum ES, Heros RC, Camarata PJ: Surgical treatment of intracranial arteriovenous malformations with an analysis of cost-effectiveness. Clin Neurosurg 42:348–369, 1995

    • Search Google Scholar
    • Export Citation
  • 22.

    Patil AA: Surgical excision of arteriovenous malformation of the cerebellum and brain stem: a case presentation. Acta Neurochir 54:117125, 1980 Patil AA: Surgical excision of arteriovenous malformation of the cerebellum and brain stem: a case presentation. Acta Neurochir 54:117–125, 1980

    • Search Google Scholar
    • Export Citation
  • 23.

    Pendl G, , Unger F, & Papaefthymiou G, et al: Staged radiosurgical treatment for large benign cerebral lesions. J Neurosurg 93 (Suppl 3):107112, 2000 Pendl G, Unger F, Papaefthymiou G, et al: Staged radiosurgical treatment for large benign cerebral lesions. J Neurosurg 93 (Suppl 3):107–112, 2000

    • Search Google Scholar
    • Export Citation
  • 24.

    Pollock BE, & Flickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:7985, 2002 Pollock BE, Flickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:79–85, 2002

    • Search Google Scholar
    • Export Citation
  • 25.

    Pollock BE, , Flickinger JC, & Lunsford LD, et al: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42:12391247, 1998 Pollock BE, Flickinger JC, Lunsford LD, et al: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42:1239–1247, 1998

    • Search Google Scholar
    • Export Citation
  • 26.

    Pollock BE, , Flickinger JC, & Lunsford LD, et al: Hemorrhage risk after stereotactic radiosurgery of cerebral arteriovenous malformations. Neurosurgery 38:652661, 1996 Pollock BE, Flickinger JC, Lunsford LD, et al: Hemorrhage risk after stereotactic radiosurgery of cerebral arteriovenous malformations. Neurosurgery 38:652–661, 1996

    • Search Google Scholar
    • Export Citation
  • 27.

    Pollock BE, , Kline RW, & Stafford SL, et al: The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 48:817824, 2000 Pollock BE, Kline RW, Stafford SL, et al: The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 48:817–824, 2000

    • Search Google Scholar
    • Export Citation
  • 28.

    Shin M, , Kawamoto S, & Kurita H, et al: Retrospective analysis of a 10-year experience of stereotactic radiosurgery for arteriovenous malformations in children and adolescents. J Neurosurg 97:779784, 2002 Shin M, Kawamoto S, Kurita H, et al: Retrospective analysis of a 10-year experience of stereotactic radiosurgery for arteriovenous malformations in children and adolescents. J Neurosurg 97:779–784, 2002

    • Search Google Scholar
    • Export Citation
  • 29.

    Solomon RA, & Stein BM: Management of arteriovenous malformations of the brain stem. J Neurosurg 64:857864, 1986 Solomon RA, Stein BM: Management of arteriovenous malformations of the brain stem. J Neurosurg 64:857–864, 1986

    • Search Google Scholar
    • Export Citation
  • 30.

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986 Spetzler RF, Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483, 1986

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 479 128 9
Full Text Views 216 26 11
PDF Downloads 134 18 4
EPUB Downloads 0 0 0