Long-term outcome of Gamma Knife stereotactic radiosurgery for arteriovenous malformations graded by the Spetzler-Martin classification

Clinical article

Michael T. Koltz M.D.1, Adam J. Polifka M.D.1, Andreas Saltos M.D.2, Robert G. Slawson M.D.2, Young Kwok M.D.2, E. Francois Aldrich M.B., Ch.B., M.Med., F.C.S.1, and J. Marc Simard M.D., Ph.D.1,3,4
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  • 1 Departments of Neurosurgery,
  • | 2 Radiation Oncology,
  • | 3 Pathology, and
  • | 4 Physiology, University of Maryland School of Medicine, Baltimore, Maryland
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Object

The object of this study was to assess outcomes in patients with arteriovenous malformations (AVMs) treated by Gamma Knife stereotactic radiosurgery (SRS); lesions were stratified by size, symptomatology, and Spetzler-Martin (S-M) grade.

Methods

The authors performed a retrospective analysis of 102 patients treated for an AVM with single-dose or staged-dose SRS between 1993 and 2004. Lesions were grouped by S-M grade, as hemorrhagic or nonhemorrhagic, and as small (< 3 cm) or large (≥ 3 cm). Outcomes included death, morbidity (new neurological deficit, new-onset seizure, or hemorrhage/rehemorrhage), nidus obliteration, and Karnofsky Performance Scale score.

Results

The mean follow-up was 8.5 years (range 5–16 years). Overall nidus obliteration (achieved in 75% of patients) and morbidity (19%) correlated with lesion size and S-M grade. For S-M Grade I–III AVMs, nonhemorrhagic and hemorrhagic combined, treatment yielded obliteration rates of 100%, 89%, and 86%, respectively; high functional status (Karnofsky Performance Scale Score ≥ 80); and 1% mortality. For S-M Grade IV and V AVMs, outcomes were less favorable, with obliteration rates of 54% and 0%, respectively. The AVMs that were not obliterated had a mean reduction in nidus volume of 69% (range 35%–96%). On long-term follow-up, 10% of patients experienced hemorrhage/rehemorrhage (6% mortality rate), which correlated with lesion size and S-M grade; the mean interval to hemorrhage was 81 months.

Conclusions

For patients with S-M Grade I–III AVMs, SRS offers outcomes that are favorable and that, except for the timing of obliteration, appear to be comparable to surgical outcomes reported for the same S-M grades. Staged-dose SRS results in lesion obliteration in half of patients with S-M Grade IV lesions.

Abbreviations used in this paper:

AVM = arteriovenous malformation; DSA = digital subtraction angiography; mRBAS = modified radiosurgery-based arteriovenous malformation grading scale; NBCA = N-butyl cyanoacrylate; S-M = Spetzler-Martin; SRS = stereotactic radiosurgery.

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  • 1

    Achrol AS, , Guzman R, , Varga M, , Adler JR, , Steinberg GK, & Chang SD: Pathogenesis and radiobiology of brain arteriovenous malformations: implications for risk stratification in natural history and posttreatment course. Neurosurg Focus 26:5 E9, 2009

    • Search Google Scholar
    • Export Citation
  • 2

    Andrade-Souza YM, , Zadeh G, , Ramani M, , Scora D, , Tsao MN, & Schwartz ML: Testing the radiosurgery-based arteriovenous malformation score and the modified Spetzler-Martin grading system to predict radiosurgical outcome. J Neurosurg 103:642648, 2005

    • Search Google Scholar
    • Export Citation
  • 3

    Colombo F, , Benedetti A, , Pozza F, , Marchetti C, & Chierego G: Linear accelerator radiosurgery of cerebral arteriovenous malformations. Neurosurgery 24:833840, 1989

    • Search Google Scholar
    • Export Citation
  • 4

    Friedman WA, , Bova FJ, , Bollampally S, & Bradshaw P: Analysis of factors predictive of success or complications in arteriovenous malformation radiosurgery. Neurosurgery 52:296308, 2003

    • Search Google Scholar
    • Export Citation
  • 5

    Hamilton MG, & Spetzler RF: The prospective application of a grading system for arteriovenous malformations. Neurosurgery 34:27, 1994

  • 6

    Hernesniemi JA, , Dashti R, , Juvela S, , Väärt K, , Niemelä M, & Laakso A: Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery 63:823831, 2008

    • Search Google Scholar
    • Export Citation
  • 7

    Heros RC, , Korosue K, & Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570578, 1990

    • Search Google Scholar
    • Export Citation
  • 8

    Kim H, , Sidney S, , McCulloch CE, , Poon KY, , Singh V, & Johnston SC, et al.: Racial/ethnic differences in longitudinal risk of intracranial hemorrhage in brain arteriovenous malformation patients. Stroke 38:24302437, 2007

    • Search Google Scholar
    • Export Citation
  • 9

    Lawton MT: Spetzler-Martin Grade III arteriovenous malformations: surgical results and a modification of the grading scale. Neurosurgery 52:740749, 2003

    • Search Google Scholar
    • Export Citation
  • 10

    Liscák R, , Vladyka V, , Simonová G, , Urgosík D, , Novotný J Jr, & Janousková L, et al.: Arteriovenous malformations after Leksell gamma knife radiosurgery: rate of obliteration and complications. Neurosurgery 60:10051016, 2007

    • Search Google Scholar
    • Export Citation
  • 11

    Lunsford LD, , Niranjan A, , Kondziolka D, , Sirin S, & Flickinger JC: Arteriovenous malformation radiosurgery: a twenty year perspective. Clin Neurosurg 55:108119, 2008

    • Search Google Scholar
    • Export Citation
  • 12

    Meder JF, , Oppenheim C, , Blustajn J, , Nataf F, , Merienne L, & Lefkoupolos D, et al.: Cerebral arteriovenous malformations: the value of radiologic parameters in predicting response to radiosurgery. AJNR Am J Neuroradiol 18:14731483, 1997

    • Search Google Scholar
    • Export Citation
  • 13

    Nataf F, , Schlienger M, , Bayram M, , Ghossoub M, , George B, & Roux FX: Microsurgery or radiosurgery for cerebral arteriovenous malformations? A study of two paired series. Neurosurgery 61:3950, 2007

    • Search Google Scholar
    • Export Citation
  • 14

    Ogilvy CS, , Stieg PE, , Awad I, , Brown RD Jr, , Kondziolka D, & Rosenwasser R, et al.: AHA Scientific Statement: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 32:14581471, 2001

    • Search Google Scholar
    • Export Citation
  • 15

    Ogilvy CS, , Stieg PE, , Awad I, , Brown RD Jr, , Kondziolka D, & Rosenwasser R, et al.: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 103:26442657, 2001

    • Search Google Scholar
    • Export Citation
  • 16

    Pandey P, , Marks MP, , Harraher CD, , Westbroek EM, , Chang SD, & Do HM, et al.: Multimodality management of Spetzler-Martin Grade III arteriovenous malformations. Clinical article. J Neurosurg 116:12791288, 2012

    • Search Google Scholar
    • Export Citation
  • 17

    Pollock BE, & Flickinger JC: Modification of the radiosurgery-based arteriovenous malformation grading system. Neurosurgery 63:239243, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Pollock BE, & Flickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:7985, 2002

  • 19

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

    • Search Google Scholar
    • Export Citation
  • 20

    Pollock BE, , Gorman DA, & Coffey RJ: Patient outcomes after arteriovenous malformation radiosurgical management: results based on a 5- to 14-year follow-up study. Neurosurgery 52:12911297, 2003

    • Search Google Scholar
    • Export Citation
  • 21

    Raffa SJ, , Chi YY, , Bova FJ, & Friedman WA: Validation of the radiosurgery-based arteriovenous malformation score in a large linear accelerator radiosurgery experience. Clinical article. J Neurosurg 111:832839, 2009

    • Search Google Scholar
    • Export Citation
  • 22

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

  • 23

    Stapf C: The rationale behind “A Randomized Trial of Unruptured Brain AVMs” (ARUBA). Acta Neurochir Suppl 107:8385, 2010

  • 24

    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

    • Search Google Scholar
    • Export Citation
  • 25

    Steinmeier R, , Schramm J, , Müller HG, & Fahlbusch R: Evaluation of prognostic factors in cerebral arteriovenous malformations. Neurosurgery 24:193200, 1989

    • Search Google Scholar
    • Export Citation
  • 26

    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

    • Search Google Scholar
    • Export Citation
  • 27

    Yamamoto M, , Jimbo M, , Hara M, , Saito I, & Mori K: Gamma knife radiosurgery for arteriovenous malformations: long-term follow-up results focusing on complications occurring more than 5 years after irradiation. Neurosurgery 38:906914, 1996

    • Search Google Scholar
    • Export Citation

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