Stereotactic radiosurgery for arteriovenous malformations after embolization: a case-control study

Clinical article

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Object

In this paper the authors' goal was to define the long-term benefits and risks of stereotactic radiosurgery (SRS) for patients with arteriovenous malformations (AVMs) who underwent prior embolization.

Methods

Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 120 patients underwent embolization followed by SRS. In this series, 64 patients (53%) had at least one prior hemorrhage. The median number of embolizations varied from 1 to 5. The median target volume was 6.6 cm3 (range 0.2–26.3 cm3). The median margin dose was 18 Gy (range 13.5–25 Gy).

Results

After embolization, 25 patients (21%) developed symptomatic neurological deficits. The overall rates of total obliteration documented by either angiography or MRI were 35%, 53%, 55%, and 59% at 3, 4, 5, and 10 years, respectively. Factors associated with a higher rate of AVM obliteration were smaller target volume, smaller maximum diameter, higher margin dose, timing of embolization during the most recent 10-year period (1997–2006), and lower Pollock-Flickinger score. Nine patients (8%) had a hemorrhage during the latency period, and 7 patients died of hemorrhage. The actuarial rates of AVM hemorrhage after SRS were 0.8%, 3.5%, 5.4%, 7.7%, and 7.7% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 2.7%. Factors associated with a higher risk of hemorrhage after SRS were a larger target volume and a larger number of prior hemorrhages. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 3 patients (2.5%) after SRS, and 1 patient had delayed cyst formation 210 months after SRS. No patient died of AREs. A larger 12-Gy volume was associated with higher risk of symptomatic AREs. Using a case-control matched approach, the authors found that patients who underwent embolization prior to SRS had a lower rate of total obliteration (p = 0.028) than patients who had not undergone embolization.

Conclusions

In this 20-year experience, the authors found that prior embolization reduced the rate of total obliteration after SRS, and that the risks of hemorrhage during the latency period were not affected by prior embolization. For patients who underwent embolization to volumes smaller than 8 cm3, success was significantly improved. A margin dose of 18 Gy or more also improved success. In the future, the role of embolization after SRS should be explored.

Abbreviations used in this paper:ARE = adverse radiation effect; AVM = arteriovenous malformation; HR = hazard ratio; NBCA = N-butyl cyanoacrylate; 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 May 25, 2012; DOI: 10.3171/2012.4.JNS111935.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Upper: Kaplan-Meier curves for total obliteration documented by MRI or angiography post-SRS for AVMs with corrected time (solid line). Uncorrected Kaplan-Meier curves for total obliteration documented by MRI or angiography post-SRS for AVMs with uncorrected times (broken line). Lower: Kaplan-Meier curves for total obliteration documented by angiography alone after radiosurgery for AVMs with corrected time (solid line). Uncorrected Kaplan-Meier curves for total obliteration documented by angiography alone post-SRS for AVMs with uncorrected time (broken line).

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    Upper: Kaplan-Meier curves of total obliteration on angiography after SRS for AVMs with a target volume of 8 cm3 or larger versus smaller than 8 cm3. A target volume smaller than 8 cm3 after SRS was significantly associated with a higher total obliteration rate documented by MRI or angiography (p = 0.002). Lower: Kaplan-Meier curves of total obliteration documented by MRI or angiography after SRS for AVMs with a margin dose of 18 Gy or greater versus less than 18 Gy. A margin dose of 18 Gy or greater after SRS was significantly associated with a higher total obliteration rate on angiography (p < 0.0001).

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    Upper: Kaplan-Meier curves of hemorrhage rate after SRS for AVMs. Lower: Kaplan-Meier curves of hemorrhage rate after SRS for AVMs with a target volume of 8 cm3 or larger versus smaller than 8 cm3. A target volume of greater than 8 cm3 after SRS was significantly associated with a higher hemorrhage rate (p = 0.012).

  • View in gallery

    Upper: Kaplan-Meier curves of total obliteration documented by MRI or angiography after SRS for AVMs with prior embolization (solid line). Kaplan-Meier curves of total obliteration documented on MRI or angiography after SRS for AVMs without prior embolization (broken line). Patients with AVMs who underwent SRS with prior embolization had a significantly lower rate of total obliteration documented by MRI or angiography (p = 0.028). Lower: Kaplan-Meier curves of hemorrhage rate after SRS for AVMs with prior embolization (solid line). Kaplan-Meier curves of hemorrhage rate after SRS for AVMs without prior embolization (broken line). Prior embolization was not associated with a reduced hemorrhage rate.

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