Clinical outcome of radiosurgery for cerebral arteriovenous malformations

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✓ The clinical outcomes are described for 247 consecutive cases of arteriovenous malformation (AVM) treated with the gamma knife between April, 1970, and December 31, 1983. Headache resolved in 65 (66.3%) of the 98 patients presenting with this symptom and improved in an additional nine (9.2%). Of 59 patients admitted with seizures, 11 (18.6%) became seizure-free without anticonvulsant medication and an additional 30 patients (50.8%) became seizure-free with anticonvulsant medication. Pre-existing neurological deficits improved or totally disappeared following radiosurgery in 56.7% of affected cases. This improvement presumably occurred within the frame of the natural history.

The protective effect of the ionizing beams against hemorrhage in incompletely obliterated AVM's is analyzed. To assess the rate of rebleeding, probability estimates were calculated using both the person-year method and the Kaplan-Meier life table. With the person-year method the actual rebleed rate is not too different from the values observed in the natural history of the disease (2% to 3%/yr). Analysis by Kaplan-Meier life-table estimates demonstrated a risk of nearly 3.7%/yr until 60 months after radiosurgery. Five years following treatment, the life table ends in a plateau which could be interpreted as an indication of decrease in the risk of hemorrhage. However, long flat regions at the right end of the life table do not imply that the real risk of rebleeding is negligible unless a large number of patients have been followed well into or beyond the flat region.

Article Information

Address for Dr. Adler: Department of Neurosurgery, Stanford Medical Center, Stanford, California.Address for Dr. Torner: Department of Preventive Medicine and Environmental Health, University of Iowa, Iowa City, Iowa.Address reprint requests to: Ladislau Steiner, M.D., Ph.D., Department of Neurological Surgery, University of Virginia, Health Sciences Center, Box 212, Charlottesville, Virginia 22908.

© AANS, except where prohibited by US copyright law.

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Figures

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    A and B: Carotid angiograms before radiosurgery in the lateral (A) and in the frontal (B) projections show an arteriovenous malformation (AVM) in the left basal ganglia. C and D: Two years after radiosurgery, lateral (C) and frontal (D) projections confirm that the malformation is obliterated.

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    Graph showing rate of rebleeding in nonobliterated arteriovenous malformations (AVM's). Curves show the percent probability of rebleeding following treatment of patients where the AVM received radiation of at least 10 Gy. Cases of rebleeding in the incubation period of obliteration (prior to 24 months) are excluded. The Kaplan-Meier life-table estimates are calculated based on time to bleeding, and the person-year estimates are calculated by the number of events per overall follow-up times.

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    Upper: Pie graphs showing the number of patients with headache before (left) and after (right) radiosurgery. The striped field denotes patients with improvement after treatment, the stippled field denotes unimproved patients, and the open field illustrates the patients without headache. Lower: Pie graphs showing the number of patients with seizure disorder before (left) and after (right) radiosurgery. The striped field denotes patients with complete seizure control on medication, the stippled field denotes patients unchanged after treatment, and the open field denotes cases without seizures and no medication. Eleven patients developed seizures after treatment.

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