Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study

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OBJECTIVE

Due to the complexity of Spetzler-Martin (SM) Grade IV–V arteriovenous malformations (AVMs), the management of these lesions remains controversial. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after single-session stereotactic radiosurgery (SRS) for SM Grade IV–V AVMs and determine predictive factors.

METHODS

The authors retrospectively pooled data from 233 patients (mean age 33 years) with SM Grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at 8 participating centers in the International Gamma Knife Research Foundation. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cm3, 17.3 Gy, and 84.5 months, respectively. Statistical analyses were performed to identify factors associated with post-SRS outcomes.

RESULTS

At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37%, and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (p = 0.04) was found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM Grade IV–V AVMs compared with ruptured ones (p = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (p = 0.024) and radiologically evident RIC (p = 0.05) in the respective multivariate analyses.

CONCLUSIONS

In this multi-institutional study, single-session SRS had limited efficacy in the management of SM Grade IV–V AVMs. Favorable outcome was only achieved in a minority of unruptured SM Grade IV–V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume-staged SRS approach for large AVMs represents an alternative approach for high-grade AVMs, but it requires further investigation.

ABBREVIATIONS AVM = arteriovenous malformation; IGKRF = International Gamma Knife Research Foundation; RBAS = radiosurgery-based AVM score; RIC = radiation-induced changes; SM = Spetzler-Martin; SRS = stereotactic radiosurgery; VRAS = Virginia Radiosurgery AVM Scale.

Article Information

Correspondence Jason Sheehan, University of Virginia, Department of Neurosurgery, PO Box 800212, Charlottesville, VA 22908. email: jps2f@virginia.edu.

INCLUDE WHEN CITING Published online September 8, 2017; DOI: 10.3171/2017.3.JNS162635.

Disclosures Dr. Grills reports having stock ownership and serving on the Board of Directors of a company called Greater Michigan Gamma Knife, and Dr. Grills reports receiving funding for non–study-related research from Elekta through her institution. Dr. Lee reports an ownership interest in VisionSense. Dr. Lunsford reports a consultant relationship with Insightec and stock ownership in Elekta.

© AANS, except where prohibited by US copyright law.

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Figures

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    Kaplan-Meier curve showing the actuarial obliteration rate following single-session SRS, with 95% confidence interval, for the SM Grade IV–V AVM cohort. The number of patients remaining at each time point is noted under the x-axis. Figure is available in color online only.

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