Stereotactic radiosurgery for arteriovenous malformations of the brain

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✓ Stereotactic radiosurgery successfully obliterates carefully selected arteriovenous malformations (AVM's) of the brain. In an initial 3-year experience using the 201-source cobalt-60 gamma knife at the University of Pittsburgh, 227 patients with AVM's were treated. Symptoms at presentation included prior hemorrhage in 143 patients (63%), headache in 104 (46%), and seizures in 70 (31%). Neurological deficits were present in 102 patients (45%). Prior surgical resection (resulting in subtotal removal) had been performed in 36 patients (16%). In 47 selected patients (21%), embolization procedures were performed in an attempt to reduce the AVM size prior to radiosurgery. The lesions were classified according to the Spetzler grading system: 64 (28%) were Grade VI (inoperable), 22 (10%) were Grade IV, 90 (40%) were Grade III, 43 (19%) were Grade II, and eight (4%) were Grade I. With the aid of computer imaging-integrated isodose plans for single-treatment irradiation, total coverage of the AVM nidus was possible in 216 patients (95%). The location and volume of the AVM were the most important factors for the selection of radiation dose. Magnetic resonance (MR) imaging was performed at 6-month intervals in 161 patients. Seventeen patients who had MR evidence of complete obliteration underwent angiography within 3 months of imaging: in 14 (82%) complete obliteration was confirmed. Complete angiographic obliteration was confirmed in 37 (80%) of 46 patients at 2 years, the earliest confirmation being 4 months (mean 17 months) after radiosurgery. The 2-year obliteration rates according to volume were: all eight (100%) AVM's less than 1 cu cm; 22 (85%) of 26 AVM's of 1 to 4 cu cm; and seven (58%) of 12 AVM's greater than 4 cu cm. Magnetic resonance imaging revealed postirradiation changes in 38 (24%) of 161 patients at a mean interval of 10.2 months after radiosurgery; only 10 (26%) of those 38 patients were symptomatic. In the entire series, two patients developed permanent new neurological deficits believed to be treatment-related. Two patients died of repeat hemorrhage at 6 and 23 months after treatment during the latency interval prior to obliteration.

Stereotactic radiosurgery is an important method to obliterate AVM's, especially those previously considered inoperable. Success and complication risks are related to the AVM location and the volume treated.

Article Information

Address for Dr. Coffey: Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.

Address reprint requests to: L. Dade Lunsford, M.D., Department of Neurological Surgery, Presbyterian-University Hospital, Room 9402, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213.

© AANS, except where prohibited by US copyright law.

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    Subtraction angiograms, lateral (left) and anteroposterior (right) views, in a 53-year-old woman with an arteriovenous malformation (AVM) in the right motor cortex. (See also Fig. 7.) A and B: Studies at the time of radiosurgery. The arrowheads indicate the 90% isodose line, the long arrows the 62% isodose line, and the short arrows the 20% isodose line. At radiosurgery, 25 Gy was administered to the 62% isodose line using one isocenter of irradiation with the 18-mm collimator (total dose 40 Gy). Note the large caliber of the callosomarginal feeding artery. C and D: Studies obtained 2 years after radiosurgery showing complete obliteration of the AVM. The caliber of the callosomarginal artery is now normal.

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    Subtraction angiograms, lateral (left) and anteroposterior (right) views, in a 19-year-old woman with an arteriovenous malformation (AVM) of the pons and right middle cerebellar peduncle. A and B: Angiograms at the time of radiosurgery. C and D: Studies obtained 2 years after radiosurgery showing complete obliteration of the AVM.

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    Studies in a 29-year-old man with an arteriovenous malformation (AVM) of the dorsal midbrain. A: Lateral subtraction angiogram before radiosurgery. B: Lateral subtraction angiogram 2 years after treatment demonstrating complete obliteration of the AVM. C: Computerized tomography scan with contrast enhancement before radiosurgery showing an AVM of the dorsal midbrain and pineal region with prominent deep venous drainage. D: Magnetic resonance T2-weighted spin-echo image obtained 2 years after treatment showing no flow-void area in the pineal region, suggestive of complete AVM obliteration.

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    Subtraction angiograms, anteroposterior view, in a 25-year-old man with a large arteriovenous malformation (AVM) in the right frontoparietal region. A: Angiogram before radiosurgery. B: Angiogram obtained 1 year after radiosurgery showing a slight decrease in size of the AVM. A prominent large draining vein is visible. C: Angiogram obtained 2 years after treatment showing major but incomplete obliteration of the AVM nidus, and persistence of an early draining vein from the malformation (arrow). D: Angiogram obtained 3 years after radiosurgery showing complete obliteration of the AVM.

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    A and B: Subtraction angiograms, lateral (A) and anteroposterior (B) views, before radiosurgery in a 23-year-old woman with a midbrain arteriovenous malformation (AVM). C, D, and E: Magnetic resonance T2-weighted spin-echo images. C: Image before radiosurgery showing the flow-void pattern of a large midbrain AVM (arrow). D: Image obtained 12 months after radiosurgery showing significant loss of flow-void area suggesting AVM obliteration. A region of high signal intensity can be seen in the area of the obliterated AVM. Both adjacent posterior cerebral arteries are seen to be patent. E: Image obtained 18 months after treatment suggesting complete obliteration, with reduction in size of the high-signal region.

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    Magnetic resonance T2-weighted spin-echo images in a 28-year-old man with an arteriovenous malformation (AVM) of the motor cortex. A: Image obtained 6 months after radiosurgery showing a region of increased signal consistent with radiation-induced “edema.” The patient developed arm paresis. B: Image obtained 12 months after radiosurgery showing a smaller region of increased signal. Marked neurological improvement had occurred. C: Image obtained 18 months after treatment. The increased signal is almost completely resolved and the AVM (arrow) appears to be obliterated. The patient's arm and hand strength had returned to almost normal.

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    Magnetic resonance T1-weighted spin-echo image in a 53-year-old woman with an arteriovenous malformation (AVM) of the motor cortex (same patient as depicted in Fig. 1). A: Image obtained before radiosurgery. B: Image obtained 6 months after treatment. The AVM is slightly smaller in size and a region of increased signal (arrows) can be seen around the AVM. The patient remained in normal neurological condition. C: Image obtained 12 months after radiosurgery. The AVM is obliterated further, but the region of increased signal (arrows) is still seen around the AVM. D: Image obtained 18 months after treatment, suggesting complete AVM obliteration. The surrounding brain appears normal.

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