Radiosurgery for Cerebral Arteriovenous Malformations in Elderly Patients: Effect of Advanced Age on Outcomes After Intervention

Starke

Kano

et al. 2017

JNS

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OBJECTIVE Because of the angioarchitectural diversity of Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs), the management of these lesions is incompletely defined. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after stereotactic radiosurgery (SRS) for SM Grade III AVMs and to determine the factors predicting these outcomes. METHODS The authors analyzed and pooled data from patients with SM Grade III AVMs treated with SRS at 8 institutions participating in the International Gamma Knife Research Foundation. Patients with these AVMs and a minimum follow-up length of 12 months were included in the study cohort. An optimal outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Data were analyzed by univariate and multivariate regression analyses. RESULTS The SM Grade III AVM cohort comprised 891 patients with a mean age of 34 years at the time of SRS. The mean nidus volume, radiosurgical margin dose, and follow-up length were 4.5 cm, 20 Gy, and 89 months, respectively. The actuarial obliteration rates at 5 and 10 years were 63% and 78%, respectively. The annual postradiosurgery hemorrhage rate was 1.2%. Symptomatic and permanent RICs were observed in 11% and 4% of the patients, respectively. Optimal outcome was achieved in 56% of the patients and was significantly more frequent in cases of unruptured AVMs (OR 2.3, p < 0.001). The lack of a previous hemorrhage (p = 0.037), absence of previous AVM embolization (p = 0.002), smaller nidus volume (p = 0.014), absence of AVM-associated arterial aneurysms (p = 0.023), and higher margin dose (p < 0.001) were statistically significant independent predictors of optimal outcome in a multivariate analysis. CONCLUSIONS Stereotactic radiosurgery provided better outcomes for patients with small, unruptured SM Grade III AVMs than for large or ruptured SM Grade III nidi. A prospective trial or registry that facilitates a comparison of SRS with conservative AVM management might further clarify the authors' observations for these often high-risk AVMs.

Section: Indications For Intervention and Treatment Outcomes For Sm Gmentioning

confidence: 99%

Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations: an international multicenter study

Starke

Kano

et al. 2017

JNS

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“…[22][23][24][25] Radiosurgery is a minimally invasive modality for the treatment of AVMs, and it is especially favorable, relative to microsurgery, for small-to moderate-sized AVMs in eloquent or deep brain areas. [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] The results of many previous radiosurgery series are confounded by the inclusion of patients who were previously treated with surgical resection, embolization, and fractionated radiation therapy. Thus, comparing the outcomes of these unfiltered studies to those of the interventional arm of ARUBA cannot lead to generalizable conclusions.…”

Section: February 2016mentioning

confidence: 99%

Radiosurgery for Cerebral Arteriovenous Malformations in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)-Eligible Patients

Starke²,

Kano³

et al. 2016

Stroke

Self Cite

114

Background and Purpose— The benefit of intervention for patients with unruptured cerebral arteriovenous malformations (AVMs) was challenged by results demonstrating superior clinical outcomes with conservative management from A Randomized Trial of Unruptured Brain AVMs (ARUBA). The aim of this multicenter, retrospective cohort study is to analyze the outcomes of stereotactic radiosurgery for ARUBA-eligible patients. Methods— We combined AVM radiosurgery outcome data from 7 institutions participating in the International Gamma Knife Research Foundation. Patients with ≥12 months of follow-up were screened for ARUBA eligibility criteria. Favorable outcome was defined as AVM obliteration, no postradiosurgery hemorrhage, and no permanently symptomatic radiation–induced changes. Adverse neurological outcome was defined as any new or worsening neurological symptoms or death. Results— The ARUBA-eligible cohort comprised 509 patients (mean age, 40 years). The Spetzler–Martin grade was I to II in 46% and III to IV in 54%. The mean radiosurgical margin dose was 22 Gy and follow-up was 86 months. AVM obliteration was achieved in 75%. The postradiosurgery hemorrhage rate during the latency period was 0.9% per year. Symptomatic and permanent radiation–induced changes occurred in 11% and 3%, respectively. The rates of favorable outcome, adverse neurological outcome, permanent neurological morbidity, and mortality were 70%, 13%, 5%, and 4%, respectively. Conclusions— Radiosurgery may provide durable clinical benefit in some ARUBA-eligible patients. On the basis of the natural history of untreated, unruptured AVMs in the medical arm of ARUBA, we estimate that a follow-up duration of 15 to 20 years is necessary to realize a potential benefit of radiosurgical intervention for conservative management in unruptured patients with AVM.

“…The elevated risk of both initial and repeat hemorrhage for these deep-seated CCMs compared to cortical CCMs favors intervention, whereas the relatively high rate of neurological morbidity associated with surgical resection of these lesions supports a more conservative approach 41)42). Although radiosurgery is a conceptually attractive alternative to surgical resection of eloquent CCMs, the radiosurgery-induced complication rate is significantly higher for CCMs than for AVMs, and CCMs cannot be radiologically monitored for obliteration after radiosurgery 3)5)6)8)9)10)12)13)14)15)16)17)18)19)20)21)22)23)25)26)27)28)29)30)31)32)33)34)35)36)37)43)44)49)50)52)53)56)59)63)64)65)66)67)68). Instead, the proposed effect of radiosurgery on CCMs is a decreased risk of symptomatic hemorrhages, which is controversial due to temporal clustering of CCM hemorrhages 4).…”

Section: Discussionmentioning

confidence: 99%

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

J Cerebrovasc Endovasc Neurosurg

Starke

Crowley

et al. 2017

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ObjectiveSurgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem.Materials and MethodsWe reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated.ResultsA total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%.ConclusionMicroneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.