Adverse radiation effects in volume-staged radiosurgery for large arteriovenous malformations: a multiinstitutional study

View More View Less
  • 1 Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan;
  • | 2 Department of Radiation Oncology, University of California, San Francisco, California;
  • | 3 Department of Neurological Surgery, Miami Neuroscience Institute, Miami, Florida;
  • | 4 Department of Neurosurgery, University of Pittsburgh;
  • | 5 Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;
  • | 6 Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic;
  • | 7 Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan;
  • | 8 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • | 9 Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico;
  • | 10 Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut;
  • | 11 Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
  • | 12 Department of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

The optimal treatment paradigm for large arteriovenous malformations (AVMs) is controversial. One approach is volume-staged stereotactic radiosurgery (VS-SRS). The authors previously reported efficacy of VS-SRS for large AVMs in a multiinstitutional cohort; here they focus on risk of symptomatic adverse radiation effects (AREs).

METHODS

This is a multicentered retrospective review of patients treated with a planned prospective volume staging approach to stereotactically treat the entire nidus of an AVM, with volume stages separated by intervals of 3–6 months. A total of 9 radiosurgical centers treated 257 patients with VS-SRS between 1991 and 2016. The authors evaluated permanent, transient, and total ARE events that were symptomatic.

RESULTS

Patients received 2–4 total volume stages. The median age was 33 years at the time of the first SRS volume stage, and the median follow-up was 5.7 years after VS-SRS. The median total AVM nidus volume was 23.25 cm3 (range 7.7–94.4 cm3), with a median margin dose per stage of 17 Gy (range 12–20 Gy). A total of 64 patients (25%) experienced an ARE, of which 19 were permanent. Rather than volume, maximal linear dimension in the Z (craniocaudal) dimension was associated with toxicity; a threshold length of 3.28 cm was associated with an ARE, with a 72.5% sensitivity and a 58.3% specificity. In addition, parietal lobe involvement for superficial lesions and temporal lobe involvement for deep lesions were associated with an ARE.

CONCLUSIONS

Size remains the dominant predictor of toxicity following SRS, but overall rates of AREs were lower than anticipated based on baseline features, suggesting that dose and size were relatively dissociated through volume staging. Further techniques need to be assessed to optimize outcomes.

ABBREVIATIONS

ARE = adverse radiation effect; AVM = arteriovenous malformation; IGKRF = International Gamma Knife Research Foundation; ROC = receiver operating characteristic; SM = Spetzler-Martin; SRS = stereotactic radiosurgery; VS-SRS = volume-staged SRS; V12 Gy = volume receiving 12 Gy.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383(9917):614621.

    • Search Google Scholar
    • Export Citation
  • 2

    Stefani MA, Porter PJ, terBrugge KG, et al. Large and deep brain arteriovenous malformations are associated with risk of future hemorrhage. Stroke. 2002;33(5):12201224.

    • Search Google Scholar
    • Export Citation
  • 3

    Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476483.

  • 4

    Lawton MT, Kim H, McCulloch CE, et al. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4):702713.

    • Search Google Scholar
    • Export Citation
  • 5

    Maruyama K, Kawahara N, Shin M, et al. The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med. 2005;352(2):146153.

    • Search Google Scholar
    • Export Citation
  • 6

    Ding D, Chen CJ, Starke RM, et al. Risk of brain arteriovenous malformation hemorrhage before and after stereotactic radiosurgery. Stroke. 2019;50(6):13841391.

    • Search Google Scholar
    • Export Citation
  • 7

    Flickinger JC, Kondziolka D, Lunsford LD, et al. Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Int J Radiat Oncol Biol Phys. 2000;46(5):11431148.

    • Search Google Scholar
    • Export Citation
  • 8

    Flickinger JC, Kondziolka D, Maitz AH, Lunsford LD. An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol. 2002;63(3):347354.

    • Search Google Scholar
    • Export Citation
  • 9

    Pollock BE, Kline RW, Stafford SL, et al. The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys. 2000;48(3):817824.

    • Search Google Scholar
    • Export Citation
  • 10

    Nagy G, Grainger A, Hodgson TJ, et al. Staged-volume radiosurgery of large arteriovenous malformations improves outcome by reducing the rate of adverse radiation effects. Neurosurgery. 2017;80(2):180192.

    • Search Google Scholar
    • Export Citation
  • 11

    Seymour ZA, Sneed PK, Gupta N, et al. Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm. J Neurosurg. 2016;124(1):163174.

    • Search Google Scholar
    • Export Citation
  • 12

    Kano H, Kondziolka D, Flickinger JC, et al. Stereotactic radiosurgery for arteriovenous malformations, Part 6: multistaged volumetric management of large arteriovenous malformations. J Neurosurg. 2012;116(1):5465.

    • Search Google Scholar
    • Export Citation
  • 13

    Seymour ZA, Chan JW, Sneed PK, et al. Dose response and architecture in volume staged radiosurgery for large arteriovenous malformations: a multi-institutional study. Radiother Oncol. 2020;144:180188.

    • Search Google Scholar
    • Export Citation
  • 14

    Deng X, Zhang Y, Xu L, et al. Comparison of language cortex reorganization patterns between cerebral arteriovenous malformations and gliomas: a functional MRI study. J Neurosurg. 2015;122(5):9961003.

    • Search Google Scholar
    • Export Citation
  • 15

    Rousseau PN, La Piana R, Chai XJ, et al. Brain functional organization and structure in patients with arteriovenous malformations. Neuroradiology. 2019;61(9):10471054.

    • Search Google Scholar
    • Export Citation
  • 16

    Pollock BE, Link MJ, Branda ME, Storlie CB. Incidence and management of late adverse radiation effects after arteriovenous malformation radiosurgery. Neurosurgery. 2017;81(6):928934.

    • Search Google Scholar
    • Export Citation
  • 17

    Kano H, Flickinger JC, Nakamura A, et al. How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations. J Neurosurg. 2019;130(6):18091816.

    • Search Google Scholar
    • Export Citation
  • 18

    Ilyas A, Chen CJ, Ding D, et al. Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review. J Neurosurg. 2018;128(1):154164.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 550 550 33
Full Text Views 85 85 8
PDF Downloads 114 114 13
EPUB Downloads 0 0 0