Letter: Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes

Wang, Lesheng

doi:10.1227/neu.0000000000002278

Neurosurgery

2022

DOI: 10.1227/neu.0000000000002278

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Letter: Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes

Lesheng Wang

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“…We sincerely appreciate the opportunity to respond to the Letter to the Editor from Dr Wang 1 on our recent article titled “Stereotactic radiosurgery provides long-term safety for patients with arteriovenous malformations in the diencephalon and brainstem: the optimal dose selection and long-term outcomes.” 2 We respectfully acknowledge Dr Wang for his thoughtful and encouraging comments on our study.…”

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To the Editor:We sincerely appreciate the opportunity to respond to the Letter to the Editor from Dr Wang 1 on our recent article titled "Stereotactic radiosurgery provides long-term safety for patients with arteriovenous malformations in the diencephalon and brainstem: the optimal dose selection and long-term outcomes." 2 We respectfully acknowledge Dr Wang for his thoughtful and encouraging comments on our study.The study analyzed the long-term outcomes of stereotactic radiosurgery (SRS) using the gamma knife for arteriovenous malformations (AVMs) in the diencephalon (DC) and brainstem (BS), which are difficult to access surgically; importantly, their rupture can lead to poor functional outcomes. One of the most important therapeutic factors affecting the outcome of SRS for AVMs is a prescribed radiosurgical dose. 3,4 Our study highlighted that the prescription dose should neither be too low nor too high for DC-AVMs and BS-AVMs to balance sufficient therapeutic effects and good functional preservation.Owing to fear of radiation injury to the important neuroanatomic structures clustered within the DC and BS, lower radiosurgical doses tend to be prescribed. However, this may actually reduce the chance of AVM obliteration. In fact, AVM obliteration was significantly less likely in the low-dose group (<18 Gy) than in the medium-dose (18-20 Gy) and high-dose (>20 Gy) groups. More importantly, this lower obliteration rate resulted in a higher post-SRS hemorrhage rate in the low-dose group than in the medium-dose and high-dose groups, although this difference was not statistically significant.In SRS for DC-AVMs and BS-AVMs, complete AVM obliteration is the most important contributor to good neurological outcomes. It is noteworthy that although the high-dose and medium-dose groups showed similar rates of AVM obliteration, the former was associated with a higher risk of adverse radiation effects (AREs). Although this difference did not reach statistical significance, it can potentially guide the choice of radiosurgical doses for DC-AVMs and BS-AVMs. Overall, medium-dose SRS appeared to provide a better functional outcome than the lowdose SRS which was insufficient for hemorrhage prevention and the high-dose SRS which increased the risk of AREs because of excessive irradiation.Based on our results, the optimal dose for DC-AVMs and BS-AVMs should be 18 to 20 Gy. Although this may sound slightly too aggressive, our emerging techniques, such as the integration of three-dimensional rotational angiography and tractography, will enable high-precision conformal targeting, avoiding important nerve tracts and contributing to a safer administration of the definitive dose to DC-AVMs and BS-AVMs (a representative case is shown in Figure ). [5][6][7][8][9] Nevertheless, as Dr Wang stated, further multicenter randomized controlled clinical trials are needed to validate our results because the differences were not statistically significant.

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Letter: Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes

Cited by 1 publication

References 6 publications

In Reply: Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes

In Reply: Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes

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