Stereotactic radiosurgery for arteriovenous malformations, Part 5: management of brainstem arteriovenous malformations

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In this paper, the authors' goal was to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) of the medulla, pons, and midbrain.


Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 67 patients had AVMs in the brainstem. In this series, 51 patients (76%) had a prior hemorrhage. The median target volume was 1.4 cm3 (range 0.1–13.4 cm3). The median margin dose was 20 Gy (range 14–25.6 Gy).


Obliteration of the AVMs was eventually documented in 35 patients at a median follow-up of 73 months (range 6–269 months). The actuarial rates of documentation of total obliteration were 41%, 70%, 70%, and 76% at 3, 4, 5, and 10 years, respectively. Higher rates of AVM obliteration were associated only with a higher margin dose. Four patients (6%) suffered a hemorrhage during the latency period, and 2 patients died. The rate of AVM hemorrhage after SRS was 3.0%, 3.0%, and 5.8% at 1, 5, and 10 years, respectively. The overall annual hemorrhage rate was 1.9%. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 7 patients (10%) after SRS, and a delayed cyst developed in 2 patients (3%). One patient died at an outside institution with symptoms of AREs and unrecognized hydrocephalus. Higher 12-Gy volumes and higher Spetzler-Martin grades were associated with a higher risk of symptomatic AREs. Ten of 22 patients who had ocular dysfunction before SRS had improvement, 9 were unchanged, and 3 were worse due to AREs. Eight of 14 patients who had hemiparesis before SRS improved, 5 were unchanged, and 1 was worse.


Although hemorrhage after obliteration did not occur in this series, patients remained at risk during the latency interval until obliteration occurred. Thirty-eight percent of the patients who had neurological deficits due to prior hemorrhage improved. Higher dose delivery in association with conformal and highly selective SRS is required for safe and effective radiosurgery.

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:

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.9.JNS11176.

© AANS, except where prohibited by US copyright law.



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    Kaplan-Meier curves for total obliteration as determined by postradiosurgery MR images or angiograms (upper) and angiograms alone (lower) for brainstem AVMs. Corrected (solid lines) and uncorrected (broken lines) times are shown.

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    Kaplan-Meier curves of total obliteration as established by MR imaging or angiography after SRS for brainstem AVMs with a margin dose of 20 Gy or more versus less than 20 Gy. A margin dose of 20 Gy or more was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.029).

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    Kaplan-Meier curves of bleeding rate after SRS for AVMs in the brainstem.

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    Vertebral artery angiograms obtained in a 13-year-old boy. Upper: Anterior and lateral angiograms documenting the pontomedullary junction AVM at the time of SRS. Lower: Three years after SRS, the anterior and lateral angiograms show the absence of a nidus and early venous drainage.

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    Images obtained in a 9-year-old girl who suffered a hemorrhage from an AVM in the midbrain. A: Anteroposterior and lateral vertebral artery radiosurgical angiograms. B: Axial contrast-enhanced T1- and T2-weighted MR images showing an AVM at the time of SRS. C: Four months after SRS the patient developed diplopia. Axial contrast-enhanced T1- and T2-weighted MR images reveal an area of contrast enhancement associated with T2 prolongation in the midbrain. D: Axial contrast-enhanced T1-weighted MR images obtained 10 months after SRS, showing reduction in the MR imaging signal abnormality. The patient's diplopia improved.



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