Stereotactic radiosurgery for arteriovenous malformations of the cerebellum

Clinical article

Greg Bowden M.D., M.Sc. 1 , 3 , 5 , Hideyuki Kano M.D., Ph.D. 1 , 3 , Daniel Tonetti M.S. 4 , Ajay Niranjan M.C.H., M.B.A. 1 , 3 , John Flickinger M.D. 2 , 3 and L. Dade Lunsford M.D. 1 , 3
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  • 1 Departments of Neurological Surgery and
  • 2 Radiation Oncology and
  • 3 the Center for Image-Guided Neurosurgery,
  • 4 University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
  • 5 Departnemt of Neurological Surgery, University of Western Ontario, London, Ontario, Canada
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Object

Arteriovenous malformations (AVMs) of the posterior fossa have an aggressive natural history and propensity for hemorrhage. Although the cerebellum accounts for the majority of the posterior fossa volume, there is a paucity of stereotactic radiosurgery (SRS) outcome data for AVMs of this region. The authors sought to evaluate the long-term outcomes and risks of cerebellar AVM radiosurgery.

Methods

This single-institution retrospective analysis reviewed the authors' experience with Gamma Knife surgery during the period 1987–2007. During this time 64 patients (median age 47 years, range 8–75 years) underwent SRS for a cerebellar AVM. Forty-seven patients (73%) presented with an intracranial hemorrhage. The median target volume was 3.85 cm3 (range 0.2–12.5 cm3), and the median marginal dose was 21 Gy (range 15–25 Gy).

Results

Arteriovenous malformation obliteration was confirmed by MRI or angiography in 40 patients at a median follow-up of 73 months (range 4–255 months). The actuarial rates of total obliteration were 53% at 3 years, 69% at 4 years, and 76% at 5 and 10 years. Elevated obliteration rates were statistically higher in patients who underwent AVM SRS without prior embolization (p = 0.005). A smaller AVM volume was also associated with a higher rate of obliteration (p = 0.03). Four patients (6%) sustained a hemorrhage during the latency period and 3 died. The cumulative rates of AVM hemorrhage after SRS were 6% at 1, 5, and 10 years. This correlated with an overall annual hemorrhage rate of 2.0% during the latency interval. One patient experienced a hemorrhage 9 years after confirmed MRI and angiographic obliteration. A permanent neurological deficit due to adverse radiation effects developed in 1 patient (1.6%) and temporary complications were seen in 2 additional patients (3.1%).

Conclusions

Stereotactic radiosurgery proved to be most effective for patients with smaller and previously nonembolized cerebellar malformations. Hemorrhage during the latency period occurred at a rate of 2.0% per year until obliteration occurred.

Abbreviations used in this paper:ARE = adverse radiation event; AVM = arteriovenous malformation; GKS = Gamma Knife surgery; SRS = stereotactic radiosurgery.

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Contributor Notes

Address correspondence to: Hideyuki Kano, M.D., Ph.D., Department of Neurological Surgery, University of Pittsburgh, Ste. B-400, UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213. email: kanoh@upmc.edu.

Please include this information when citing this paper: published online October 25, 2013; DOI: 10.3171/2013.9.JNS131022.

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