Radiosurgery for patients with unruptured intracranial arteriovenous malformations

Clinical article

Dale DingDepartment of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

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Chun-Po YenDepartment of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

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Zhiyuan XuDepartment of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

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Robert M. StarkeDepartment of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

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Jason P. SheehanDepartment of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia

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Object

The appropriate management of unruptured intracranial arteriovenous malformations (AVMs) remains controversial. In the present study, the authors evaluate the radiographic and clinical outcomes of radiosurgery for a large cohort of patients with unruptured AVMs.

Methods

From a prospective database of 1204 cases of AVMs involving patients treated with radiosurgery at their institution, the authors identified 444 patients without evidence of rupture prior to radiosurgery. The patients' mean age was 36.9 years, and 50% were male. The mean AVM nidus volume was 4.2 cm3, 13.5% of the AVMs were in a deep location, and 44.4% were at least Spetzler-Martin Grade III. The median radiosurgical prescription dose was 20 Gy. Univariate and multivariate Cox regression analyses were used to determine risk factors associated with obliteration, postradiosurgery hemorrhage, radiation-induced changes, and postradiosurgery cyst formation. The mean duration of radiological and clinical follow-up was 76 months and 86 months, respectively.

Results

The cumulative AVM obliteration rate was 62%, and the postradiosurgery annual hemorrhage rate was 1.6%. Radiation-induced changes were symptomatic in 13.7% and permanent in 2.0% of patients. The statistically significant independent positive predictors of obliteration were no preradiosurgery embolization (p < 0.001), increased prescription dose (p < 0.001), single draining vein (p < 0.001), radiological presence of radiation-induced changes (p = 0.004), and lower Spetzler-Martin grade (p = 0.016). Increased volume and higher Pittsburgh radiosurgery-based AVM score were predictors of postradiosurgery hemorrhage in the univariate analysis only. Clinical deterioration occurred in 30 patients (6.8%), more commonly in patients with postradiosurgery hemorrhage (p = 0.018).

Conclusions

Radiosurgery afforded a reasonable chance of obliteration of unruptured AVMs with relatively low rates of clinical and radiological complications.

Abbreviations used in this paper:

ARUBA = A Randomized Trial of Unruptured Brain Arteriovenous Malformations; AVM = arteriovenous malformation; DSA = digital subtraction angiography; HR = hazard ratio; RIC = radiation-induced change.
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  • 1

    Al-Shahi R, , Bhattacharya JJ, , Currie DG, , Papanastassiou V, , Ritchie V, & Roberts RC, et al.: Prospective, population-based detection of intracranial vascular malformations in adults: the Scottish Intracranial Vascular Malformation Study (SIVMS). Stroke 34:11631169, 2003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Andrade-Souza YM, , Ramani M, , Scora D, , Tsao MN, , terBrugge K, & Schwartz ML: Embolization before radiosurgery reduces the obliteration rate of arteriovenous malformations. Neurosurgery 60:443452, 2007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    ApSimon HT, , Reef H, , Phadke RV, & Popovic EA: A population-based study of brain arteriovenous malformation: long-term treatment outcomes. Stroke 33:27942800, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Brown RD Jr, , Wiebers DO, , Forbes G, , O'Fallon WM, , Piepgras DG, & Marsh WR, et al.: The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68:352357, 1988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Brown RD Jr, , Wiebers DO, , Torner JC, & O'Fallon WM: Incidence and prevalence of intracranial vascular malformations in Olmsted County, Minnesota, 1965 to 1992. Neurology 46:949952, 1996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Chang SD, , Shuster DL, , Steinberg GK, , Levy RP, & Frankel K: Stereotactic radiosurgery of arteriovenous malformations: pathologic changes in resected tissue. Clin Neuropathol 16:111116, 1997

    • Search Google Scholar
    • Export Citation
  • 7

    Cockroft KM: Unruptured brain arteriovenous malformations should be treated conservatively: no. Stroke 38:33103311, 2007. (Letter)

  • 8

    da Costa L, , Wallace MC, , Ter Brugge KG, , O'Kelly C, , Willinsky RA, & Tymianski M: The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 40:100105, 2009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Flickinger JC, , Kondziolka D, , Lunsford LD, , Kassam A, , Phuong LK, & Liscak R, et al.: Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Int J Radiat Oncol Biol Phys 46:11431148, 2000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Flickinger JC, , Kondziolka D, , Pollock BE, , Maitz AH, & Lunsford LD: Complications from arteriovenous malformation radiosurgery: multivariate analysis and risk modeling. Int J Radiat Oncol Biol Phys 38:485490, 1997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Graf CJ, , Perret GE, & Torner JC: Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58:331337, 1983

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Hartmann A, , Mast H, , Mohr JP, , Pile-Spellman J, , Connolly ES, & Sciacca RR, et al.: Determinants of staged endovascular and surgical treatment outcome of brain arteriovenous malformations. Stroke 36:24312435, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Hartmann A, , Stapf C, , Hofmeister C, , Mohr JP, , Sciacca RR, & Stein BM, et al.: Determinants of neurological outcome after surgery for brain arteriovenous malformation. Stroke 31:23612364, 2000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Hillman J: Population-based analysis of arteriovenous malformation treatment. J Neurosurg 95:633637, 2001

  • 15

    Jessurun GA, , Kamphuis DJ, , van der Zande FH, & Nossent JC: Cerebral arteriovenous malformations in The Netherlands Antilles. High prevalence of hereditary hemorrhagic telangiectasia-related single and multiple cerebral arteriovenous malformations. Clin Neurol Neurosurg 95:193198, 1993

    • Search Google Scholar
    • Export Citation
  • 16

    Lawton MT, , Du R, , Tran MN, , Achrol AS, , McCulloch CE, & Johnston SC, et al.: Effect of presenting hemorrhage on outcome after microsurgical resection of brain arteriovenous malformations. Neurosurgery 56:485493, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Lax I, & Karlsson B: Prediction of complications in gamma knife radiosurgery of arteriovenous malformation. Acta Oncol 35:4955, 1996

  • 18

    Mohr JP, , Moskowitz AJ, , Stapf C, , Hartmann A, , Lord K, & Marshall SM, et al.: The ARUBA trial: current status, future hopes. Stroke 41:e537e540, 2010

    • Search Google Scholar
    • Export Citation
  • 19

    Mounayer C, , Hammami N, , Piotin M, , Spelle L, , Benndorf G, & Kessler I, et al.: Nidal embolization of brain arteriovenous malformations using Onyx in 94 patients. AJNR Am J Neuroradiol 28:518523, 2007

    • Search Google Scholar
    • Export Citation
  • 20

    Ondra SL, , Troupp H, , George ED, & Schwab K: The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 73:387391, 1990

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Pollock BE, , Flickinger JC, , Lunsford LD, , Bissonette DJ, & Kondziolka D: Factors that predict the bleeding risk of cerebral arteriovenous malformations. Stroke 27:16, 1996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Pollock BE, , Flickinger JC, , Lunsford LD, , Maitz A, & Kondziolka D: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42:12391247, 1998

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Pollock BE, , Kondziolka D, , Flickinger JC, , Patel AK, , Bissonette DJ, & Lunsford LD: Magnetic resonance imaging: an accurate method to evaluate arteriovenous malformations after stereotactic radiosurgery. J Neurosurg 85:10441049, 1996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Saatci I, , Geyik S, , Yavuz K, & Cekirge HS: Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. Clinical article. J Neurosurg 115:7888, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Schlienger M, , Atlan D, , Lefkopoulos D, , Merienne L, , Touboul E, & Missir O, et al.: Linac radiosurgery for cerebral arteriovenous malformations: results in 169 patients. Int J Radiat Oncol Biol Phys 46:11351142, 2000

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Schneider BF, , Eberhard DA, & Steiner LE: Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 87:352357, 1997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Sirin S, , Kondziolka D, , Niranjan A, , Flickinger JC, , Maitz AH, & Lunsford LD: Prospective staged volume radiosurgery for large arteriovenous malformations: indications and outcomes in otherwise untreatable patients. Neurosurgery 58:1727, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986

  • 29

    Stapf C, , Mast H, , Sciacca RR, , Berenstein A, , Nelson PK, & Gobin YP, et al.: The New York Islands AVM Study: design, study progress, and initial results. Stroke 34:e29e33, 2003

    • Search Google Scholar
    • Export Citation
  • 30

    Stapf C, , Mast H, , Sciacca RR, , Choi JH, , Khaw AV, & Connolly ES, et al.: Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 66:13501355, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31

    Stapf C, & Mohr JP: Unruptured brain arteriovenous malformations should be treated conservatively: yes. Stroke 38:33083309, 2007

  • 32

    Stapf C, , Mohr JP, , Choi JH, , Hartmann A, & Mast H: Invasive treatment of unruptured brain arteriovenous malformations is experimental therapy. Curr Opin Neurol 19:6368, 2006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Steiner L, , Lindquist C, , Adler JR, , Torner JC, , Alves W, & Steiner M: Clinical outcome of radiosurgery for cerebral arteriovenous malformations. J Neurosurg 77:18, 1992

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    van Rooij WJ, , Sluzewski M, & Beute GN: Brain AVM embolization with Onyx. AJNR Am J Neuroradiol 28:172178, 2007

  • 35

    Wedderburn CJ, , van Beijnum J, , Bhattacharya JJ, , Counsell CE, , Papanastassiou V, & Ritchie V, et al.: Outcome after interventional or conservative management of unruptured brain arteriovenous malformations: a prospective, population-based cohort study. Lancet Neurol 7:223230, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Wegner RE, , Oysul K, , Pollock BE, , Sirin S, , Kondziolka D, & Niranjan A, et al.: A modified radiosurgery-based arteriovenous malformation grading scale and its correlation with outcomes. Int J Radiat Oncol Biol Phys 79:11471150, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation

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