Stereotactic radiosurgery for arteriovenous malformations, Part 4: management of basal ganglia and thalamus arteriovenous malformations

Clinical article

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Object

The authors conducted a study to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) of the basal ganglia and thalamus.

Methods

Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 56 patients had AVMs of the basal ganglia and 77 had AVMs of the thalamus. In this series, 113 (85%) of 133 patients had a prior hemorrhage. The median target volume was 2.7 cm3 (range 0.1–20.7 cm3) and the median margin dose was 20 Gy (range 15–25 Gy).

Results

Obliteration of the AVM eventually was documented on MR imaging in 78 patients and on angiography in 63 patients in a median follow-up period of 61 months (range 2–265 months). The actuarial rates documenting total obliteration after radiosurgery were 57%, 70%, 72%, and 72% at 3, 4, 5, and 10 years, respectively. Factors associated with a higher rate of AVM obliteration included AVMs located in the basal ganglia, a smaller target volume, a smaller maximum diameter, and a higher margin dose. Fifteen (11%) of 133 patients suffered a hemorrhage during the latency period and 7 patients died. The rate of post-SRS AVM hemorrhage was 4.5%, 6.2%, 9.0%, 11.2%, and 15.4% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 4.7%. When 5 patients with 7 hemorrhages occurring earlier than 6 months after SRS were removed from this analysis, the annual hemorrhage rate decreased to 2.7%. Larger volume AVMs had a higher risk of hemorrhage after SRS. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 6 patients (4.5%), and in 1 patient a delayed cyst developed 56 months after SRS. No patient died of AREs. Factors associated with a higher risk of symptomatic AREs were larger target volume, larger maximum diameter, lower margin dose, and a higher Pollock-Flickinger score.

Conclusions

Stereotactic radiosurgery is a gradually effective and relatively safe management option for deep-seated AVMs in the basal ganglia and thalamus. Although hemorrhage after obliteration did not occur in the present series, patients remain at risk during the latency interval between SRS and obliteration. The best candidates for SRS are patients with smaller volume AVMs located in the basal ganglia.

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

Article Information

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

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.9.JNS11175.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Upper: Kaplan-Meier curves for total obliteration documented on MR imaging or angiography after radiosurgery for AVMs of the basal ganglia and thalamus. The solid line indicates corrected times and the broken line uncorrected times. Lower: Kaplan-Meier curves for total obliteration by angiography alone after radiosurgery for AVMs of the basal ganglia and thalamus. The solid line indicates corrected times and the broken line uncorrected times.

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    Upper: Kaplan-Meier curves of total obliteration on MR imaging or angiography after SRS for AVMs of the basal ganglia and thalamus comparing 2 margin doses (≥ 20 Gy and < 20 Gy). A margin dose of ≥ 20 Gy was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.007). Lower: Kaplan-Meier curves of total obliteration on angiography alone after SRS for AVMs of the basal ganglia and thalamus comparing 2 target volumes (≥ 6 cm3 and < 6 cm3). A target volume of < 6 cm3 was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.008).

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    Upper: Kaplan-Meier curves of hemorrhage rate after SRS for AVMs of the basal ganglia and thalamus. Lower: Kaplan-Meier curves of hemorrhage rate after SRS for AVMs of the basal ganglia and thalamus comparing 2 target volumes (≥ 6 cm3 and < 6 cm3). A target volume of < 6 cm3 was significantly associated with a higher bleeding rate (p = 0.012).

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    Studies obtained in a 10-year-old boy without prior hemorrhage who had left hand tremor. A: Anterior and lateral vertebral artery angiograms documenting an AVM in the right thalamus at the time of SRS. B: Anterior and lateral vertebral artery angiograms acquired 3 years after SRS, showing the absence of a nidus and early venous drainage. C: Axial T1-weighted contrast-enhanced MR image showing an AVM in the left thalamus at the time of the Gamma Knife planning. D and E: Axial T1- and T2-weighted contrast-enhanced MR images obtained 3 years after SRS showing the absence of a nidus and early venous drainage.

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