Early versus late arteriovenous malformation responders after stereotactic radiosurgery: an international multicenter study

Or Cohen-Inbar Department of Neurosurgery and Gamma Knife Center, University of Virginia, Charlottesville, Virginia;

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Robert M. Starke Department of Neurosurgery and Gamma Knife Center, University of Virginia, Charlottesville, Virginia;
Department of Neurological Surgery and Radiology, University of Miami, Florida

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Gabriella Paisan Department of Neurosurgery and Gamma Knife Center, University of Virginia, Charlottesville, Virginia;

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Hideyuki Kano Department of Neurosurgery, University of Pittsburgh, Pennsylvania;

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Paul P. Huang Department of Neurosurgery, New York University Langone Medical Center, New York, New York;

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Rafael Rodriguez-Mercado Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico;

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Luis Almodovar Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico;

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Inga S. Grills Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan;

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David Mathieu Department of Neurosurgery, University of Sherbrooke, Centre de Recherche Clinique Étienne-LeBel, Sherbrooke, Quebec, Canada;

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Danilo Silva Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio;

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Mahmoud Abbassy Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio;

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Symeon Missios Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio;

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John Y. K. Lee Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and

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Gene H. Barnett Rose-Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, Ohio;

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Douglas Kondziolka Department of Neurosurgery, New York University Langone Medical Center, New York, New York;

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L. Dade Lunsford Department of Neurosurgery, University of Pittsburgh, Pennsylvania;

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Jason P. Sheehan Department of Neurosurgery and Gamma Knife Center, University of Virginia, Charlottesville, Virginia;

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OBJECTIVE

The goal of stereotactic radiosurgery (SRS) for arteriovenous malformation (AVM) is complete nidus obliteration, thereby eliminating the risk of future hemorrhage. This outcome can be observed within the first 18 months, although documentation of AVM obliteration can extend to as much as 5 years after SRS is performed. A shorter time to obliteration may impact the frequency and effect of post-SRS complications and latency hemorrhage. The authors' goal in the present study was to determine predictors of early obliteration (18 months or less) following SRS for cerebral AVM.

METHODS

Eight centers participating in the International Gamma Knife Research Foundation (IGKRF) obtained institutional review board approval to supply de-identified patient data. From a cohort of 2231 patients, a total of 1398 patients had confirmed AVM obliteration. Patients were sorted into early responders (198 patients), defined as those with confirmed nidus obliteration at or prior to 18 months after SRS, and late responders (1200 patients), defined as those with confirmed nidus obliteration more than 18 months after SRS. The median clinical follow-up time was 63.7 months (range 7–324.7 months).

RESULTS

Outcome parameters including latency interval hemorrhage, mortality, and favorable outcome were not significantly different between the 2 groups. Radiologically demonstrated radiation-induced changes were noted more often in the late responder group (376 patients [31.3%] vs 39 patients [19.7%] for early responders, p = 0.005). Multivariate independent predictors of early obliteration included a margin dose > 24 Gy (p = 0.031), prior surgery (p = 0.002), no prior radiotherapy (p = 0.025), smaller AVM nidus (p = 0.002), deep venous drainage (p = 0.039), and nidus location (p < 0.0001). Basal ganglia, cerebellum, and frontal lobe nidus locations favored early obliteration (p = 0.009). The Virginia Radiosurgery AVM Scale (VRAS) score was significantly different between the 2 responder groups (p = 0.039). The VRAS score was also shown to be predictive of early obliteration on univariate analysis (p = 0.009). For early obliteration, such prognostic ability was not shown for other SRS- and AVM-related grading systems.

CONCLUSIONS

Early obliteration (≤ 18 months post-SRS) was more common in patients whose AVMs were smaller, located in the frontal lobe, basal ganglia, or cerebellum, had deep venous drainage, and had received a margin dose > 24 Gy.

ABBREVIATIONS

AVM = arteriovenous malformation; GKRS = Gamma Knife radiosurgery; IGKRF = International Gamma Knife Research Foundation; MRA = MR angiography; RBAS = Radiosurgery-Based AVM score; RIC = radiation-induced change; SM = Spetzler-Martin; SRS = stereotactic radiosurgery; VRAS = Virginia Radiosurgery AVM Scale.
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