Long-term outcome of Gamma Knife stereotactic radiosurgery for arteriovenous malformations graded by the Spetzler-Martin classification

Clinical article

Michael T. Koltz M.D. 1 , Adam J. Polifka M.D. 1 , Andreas Saltos M.D. 2 , Robert G. Slawson M.D. 2 , Young Kwok M.D. 2 , E. Francois Aldrich M.B., Ch.B., M.Med., F.C.S. 1 and J. Marc Simard M.D., Ph.D. 1 , 3 , 4
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  • 1 Departments of Neurosurgery,
  • 2 Radiation Oncology,
  • 3 Pathology, and
  • 4 Physiology, University of Maryland School of Medicine, Baltimore, Maryland
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Object

The object of this study was to assess outcomes in patients with arteriovenous malformations (AVMs) treated by Gamma Knife stereotactic radiosurgery (SRS); lesions were stratified by size, symptomatology, and Spetzler-Martin (S-M) grade.

Methods

The authors performed a retrospective analysis of 102 patients treated for an AVM with single-dose or staged-dose SRS between 1993 and 2004. Lesions were grouped by S-M grade, as hemorrhagic or nonhemorrhagic, and as small (< 3 cm) or large (≥ 3 cm). Outcomes included death, morbidity (new neurological deficit, new-onset seizure, or hemorrhage/rehemorrhage), nidus obliteration, and Karnofsky Performance Scale score.

Results

The mean follow-up was 8.5 years (range 5–16 years). Overall nidus obliteration (achieved in 75% of patients) and morbidity (19%) correlated with lesion size and S-M grade. For S-M Grade I–III AVMs, nonhemorrhagic and hemorrhagic combined, treatment yielded obliteration rates of 100%, 89%, and 86%, respectively; high functional status (Karnofsky Performance Scale Score ≥ 80); and 1% mortality. For S-M Grade IV and V AVMs, outcomes were less favorable, with obliteration rates of 54% and 0%, respectively. The AVMs that were not obliterated had a mean reduction in nidus volume of 69% (range 35%–96%). On long-term follow-up, 10% of patients experienced hemorrhage/rehemorrhage (6% mortality rate), which correlated with lesion size and S-M grade; the mean interval to hemorrhage was 81 months.

Conclusions

For patients with S-M Grade I–III AVMs, SRS offers outcomes that are favorable and that, except for the timing of obliteration, appear to be comparable to surgical outcomes reported for the same S-M grades. Staged-dose SRS results in lesion obliteration in half of patients with S-M Grade IV lesions.

Abbreviations used in this paper:AVM = arteriovenous malformation; DSA = digital subtraction angiography; mRBAS = modified radiosurgery-based arteriovenous malformation grading scale; NBCA = N-butyl cyanoacrylate; S-M = Spetzler-Martin; SRS = stereotactic radiosurgery.

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Contributor Notes

Address correspondence to: J. Marc Simard, M.D., Ph.D., Department of Neurosurgery, University of Maryland School of Medicine, 22 South Greene Street, Suite S12D, Baltimore, Maryland 21201-1595. email: msimard@smail.umaryland.edu.

Please include this information when citing this paper: published online October 19, 2012; DOI: 10.3171/2012.9.JNS112329.

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