Stereotactic radiosurgery for arteriovenous malformations, Part 1: management of Spetzler-Martin Grade I and II arteriovenous malformations

Clinical article

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Object

The aim of this paper was to define the outcomes and risks of stereotactic radiosurgery (SRS) for Spetzler-Martin Grade I and II arteriovenous malformations (AVMs).

Methods

Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs, including 217 patients with AVMs classified as Spetzler-Martin Grade I or II. The median maximum diameter and target volumes were 1.9 cm (range 0.5–3.8 cm) and 2.3 cm3 (range 0.1–14.1 cm3), respectively. The median margin dose was 22 Gy (range 15–27 Gy).

Results

Arteriovenous malformation obliteration was confirmed by MR imaging in 148 patients and by angiography in 100 patients with a median follow-up of 64 months (range 6–247 months). The actuarial rates of total obliteration determined by angiography or MR imaging after 1 SRS procedure were 58%, 87%, 90%, and 93% at 3, 4, 5, and 10 years, respectively. The median time to complete MR imaging–determined obliteration was 30 months. Factors associated with higher AVM obliteration rates were smaller AVM target volume, smaller maximum diameter, and greater marginal dose. Thirteen patients (6%) suffered hemorrhages during the latency period, and 6 patients died. Cumulative rates of AVM hemorrhage 1, 2, 3, 5, and 10 years after SRS were 3.7%, 4.2%, 4.2%, 5.0%, and 6.1%, respectively. This corresponded to rates of annual bleeding risk of 3.7%, 0.3%, and 0.2% for Years 0–1, 1–5, and 5–10, respectively, after SRS. The presence of a coexisting aneurysm proximal to the AVM correlated with a significantly higher hemorrhage risk. Temporary symptomatic adverse radiation effects developed in 5 patients (2.3%) after SRS, and 2 patients (1%) developed delayed cysts.

Conclusions

Stereotactic radiosurgery is a gradually effective and relatively safe option for patients with smaller volume Spetzler-Martin Grade I or II AVMs who decline initial resection. Hemorrhage after obliteration did not occur in this series. Patients remain at risk for a bleeding event during the latency interval until obliteration occurs. Patients with aneurysms and an AVM warrant more aggressive surgical or endovascular treatment to reduce the risk of a hemorrhage in the latency period after SRS.

Abbreviations used in this paper: ARE = adverse radiosurgical effect; AVM = arteriovenous malformation; HR = hazard ratio; SRS = stereotactic radiosurgery.

Article Information

Address correspondence to: Douglas Kondziolka, M.D., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: kondziolkads@upmc.edu.

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.9.JNS101740.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Upper: Kaplan-Meier curves for total obliteration by MR imaging or angiography after single radiosurgery for smaller volume (Spetzler-Martin Grade I or II) AVMs with corrected time (solid line). Uncorrected Kaplan-Meier curves for total obliteration by MR imaging or angiography following single radiosurgery for smaller volume (Spetzler-Martin Grade I or II) AVMs with uncorrected time (broken line). Lower: Kaplan-Meier curves for total obliteration by angiography alone after single radiosurgery for smaller volume (Spetzler-Martin Grade I or II) AVMs with corrected time (solid line). Uncorrected Kaplan-Meier curves for total obliteration by angiography alone following single radiosurgery for smaller volume (Spetzler-Martin Grade I or II) AVMs with uncorrected time (broken line).

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    Upper: Kaplan-Meier curves of total obliteration on angiography after single SRS for Spetzler-Martin Grade I or II AVMs with a maximum diameter of 2 cm or larger versus smaller than 2 cm. A maximum diameter less than 2 cm after SRS was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.001). Lower: Kaplan-Meier curves of total obliteration on angiography after single SRS for Spetzler-Martin Grade I or II AVMs with a margin dose greater than 20 Gy versus 20 Gy or less. A margin dose greater than 20 Gy was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.022).

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    Upper: Kaplan-Meier curves of bleeding rate after SRS for Spetzler-Martin Grade I or II AVMs. Lower: Kaplan-Meier curves of bleeding rate after single SRS for Spetzler-Martin Grade I or II AVMs with or without a coexisting aneurysm. Presence of a coexisting aneurysm was significantly associated with a higher bleeding rate (p < 0.0005).

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