Stereotactic radiosurgery for arteriovenous malformations, Part 6: multistaged volumetric management of large arteriovenous malformations

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Object

The object of this study was to define the long-term outcomes and risks of arteriovenous malformation (AVM) management using 2 or more stages of stereotactic radiosurgery (SRS) for symptomatic large-volume lesions unsuitable for surgery.

Methods

In 1992, the authors prospectively began to stage the treatment of anatomical components to deliver higher single doses to AVMs with a volume of more than 10 cm3. Forty-seven patients with such AVMs underwent volume-staged SRS. In this series, 18 patients (38%) had a prior hemorrhage and 21 patients (45%) underwent prior embolization. The median interval between the first-stage SRS and the second-stage SRS was 4.9 months (range 2.8–13.8 months). The median target volume was 11.5 cm3 (range 4.0–26 cm3) in the first-stage SRS and 9.5 cm3 in the second-stage SRS. The median margin dose was 16 Gy (range 13–18 Gy) for both stages.

Results

In 17 patients, AVM obliteration was confirmed after 2–4 SRS procedures at a median follow-up of 87 months (range 0.4–209 months). Five patients had near-total obliteration (volume reduction > 75% but residual AVM). The actuarial rates of total obliteration after 2-stage SRS were 7%, 20%, 28%, and 36% at 3, 4, 5, and 10 years, respectively. The 5-year total obliteration rate after the initial staged volumetric SRS with a margin dose of 17 Gy or more was 62% (p = 0.001). Sixteen patients underwent additional SRS at a median interval of 61 months (range 33–113 months) after the initial 2-stage SRS. The overall rates of total obliteration after staged and repeat SRS were 18%, 45%, and 56% at 5, 7, and 10 years, respectively. Ten patients sustained hemorrhage after staged SRS, and 5 of these patients died. Three of 16 patients who underwent repeat SRS sustained hemorrhage after the procedure and died. Based on Kaplan-Meier analysis (excluding the second hemorrhage in the patient who had 2 hemorrhages), the cumulative rates of AVM hemorrhage after SRS were 4.3%, 8.6%, 13.5%, and 36.0% at 1, 2, 5, and 10 years, respectively. This corresponded to annual hemorrhage risks of 4.3%, 2.3%, and 5.6% for Years 0–1, 1–5, and 5–10 after SRS. Multiple hemorrhages before SRS correlated with a significantly higher risk of hemorrhage after SRS. Symptomatic adverse radiation effects were detected in 13% of patients, but no patient died as a result of an adverse radiation effect. Delayed cyst formation did not occur in any patient after SRS.

Conclusions

Prospective volume-staged SRS for large AVMs unsuitable for surgery has potential benefit but often requires more than 2 procedures to complete the obliteration process. To have a reasonable chance of benefit, the minimum margin dose should be 17 Gy or greater, depending on the AVM location. In the future, prospective volume-staged SRS followed by embolization (to reduce flow, obliterate fistulas, and occlude associated aneurysms) may improve obliteration results and further reduce the risk of hemorrhage after SRS.

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.JNS11177.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Studies obtained in a 34-year-old female patient with a large AVM located in the cingulate gyrus who presented with an intraventricular hemorrhage. A and B: Anteroposterior and lateral right internal carotid artery (ICA) angiograms obtained at the time of the volume-staged SRS. C–E: Axial, coronal, and sagittal T1-weighted contrast-enhanced MR images showing an anatomical component of the first volume-staged SRS. F–H: Axial, coronal, and sagittal T1-weighted contrast-enhanced MR images showing an anatomical component of the second volume-staged SRS (8 months after the first). The total target volume was 15.6cm3 and the margin dose was 18 Gy for both stages. I and J: Anteroposterior and lateral right ICA angiograms showing total obliteration 40 months after the second volume-staged SRS.

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    Flowchart showing outcomes after staged and repeat SRS in 47 patients. N = number of patients.

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    Upper: Kaplan-Meier curves for total obliteration on MR imaging or angiography after staged radiosurgery for large-volume AVMs with corrected time (solid line) and uncorrected time (broken line). Lower: Kaplan-Meier curves for total obliteration on MR imaging or angiography after staged SRS for large AVMs with a margin dose of 17 Gy or more versus a margin dose less than 17 Gy. A margin dose of 17 Gy or more was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.001).

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    Kaplan-Meier curve for hemorrhage rate after staged SRS for large AVMs.

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    Upper: Kaplan-Meier curves for total obliteration on MR imaging or angiography after repeat radiosurgery for residual AVMs. Lower: Kaplan-Meier curves of hemorrhage rate after repeat SRS for residual AVMs.

  • View in gallery

    Kaplan-Meier curve for total obliteration on MR imaging or angiography after staged and repeat radiosurgery.

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