Stereotactic Radiosurgery for Arteriovenous Malformations Located in Deep Critical Regions

Nagy, Gábor; Major, Ottó; Rowe, Jeremy; Radatz, Matthias; Hodgson, Timothy J.; Coley, Stuart C.; Kemeny, Andras

doi:10.1227/neu.0b013e318246a4d0

Cited by 38 publications

(25 citation statements)

References 58 publications

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“…In the SRS group, eight patients suffered post-treatment hemorrhages – all with residual AVM. Prior series of deep AVMs treated with radiosurgery have reported annual post-treatment hemorrhage rates ranging from 1.3–9.5%, depending on size, location, prior history of hemorrhage, and time since radiosurgical treatment (1,5,10,14,17). It is important to note that the post-radiosurgical hemorrhage rates in our series and prior series are lower than the natural history of deep-seated AVMs.…”

Section: Discussionmentioning

confidence: 99%

“…This obliteration rate is below that of several prior series of radiosurgery for deep-seated AVMs. Three year obliteration rates have been reported from 57–68% (5,10), with overall obliteration rates as high as 81% (1,5,7,10,11,14). There are several variables that can account for such differences.…”

Section: Discussionmentioning

confidence: 99%

“…In this series, the median marginal prescription dose was 17Gy while other large series have reported median marginal doses from 18–25Gy (5,7,11,14). Both size and marginal dose are known to be associated with AVM obliteration (3,5,7,10). …”

Section: Discussionmentioning

confidence: 99%

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Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

et al. 2014

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Objective To describe a single institution’s experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fasion. Methods We conducted a retrospective review of all deep AVMs treated at our institution between 1997–2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes. Results 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage. 29% were located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, while Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Post-treatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients). Conclusions Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared to SRS, and is associated with satisfactory results in highly selected patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

et al. 2014

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“…This result statistically demonstrated that higher obliteration rates occurred in smaller AVMs, which corresponds to the volume effect noted in previous studies. 10,12,25,43 Total obliteration occurred more frequently when a higher margin dose was applied. In this study 82% of patients receiving ≥ 22 Gy had occlusion of their AVM.…”

Section: Factors Related To Obliterationmentioning

confidence: 99%

“…16,40,41 The rates of AVM occlusion after a single Gamma Knife surgery generally range from 70% to 80% over a 5-year observation period. 6,11,19,25 In addition, stereotactic radiosurgery (SRS) has a relatively low risk profile for adverse radiation effects (AREs). …”

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confidence: 99%

Stereotactic radiosurgery for arteriovenous malformations of the postgeniculate visual pathway

Bowden

Kano

Caparosa

et al. 2015

JNS

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ManageMent options for arteriovenous malformations (AVMs) have expanded and evolved over time. However, the underlying goal of intervention remains complete obliteration of the AVM and maintenance of neurological function. 16,40,41 The rates of AVM occlusion after a single Gamma Knife surgery generally range from 70% to 80% over a 5-year observation period. 6,11,19,25 In addition, stereotactic radiosurgery (SRS) has a relatively low risk profile for adverse radiation effects (AREs). 23The lateral geniculate nucleus gives rise to the sublenticular and retrolenticular segments of the optic radiation that travel through the temporal and parietal lobes, respectively, on a path that terminates in the striate cortex. Because the distance and fragility of these pathways create the opportunity for disruption by an AVM, associabbreviatioNs ARE = adverse radiation effect; AVM = arteriovenous malformation; SRS = stereotactic radiosurgery. submitted January 8, 2014. accepted October 14, 2014. iNclude wheN citiNg Published online November 28, 2014; DOI: 10.3171/2014.10.JNS1453. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Dr. Lunsford is a consultant and stockholder for AB Elekta. , and 19 Gy (range 14-25 Gy) was the median margin dose. Obliteration of the AVM was confirmed in 80 patients after a single SRS procedure at a median follow-up of 74 months (range 5-297 months). The actuarial rate of total obliteration was 67% at 4 years. Arteriovenous malformations with a volume < 5 cm 3 had obliteration rates of 60% at 3 years and 79% at 4 years. The delivered margin dose proved significant given that 82% of patients receiving ≥ 22 Gy had complete obliteration. The AVM was completely obliterated in an additional 18 patients after they underwent repeat SRS. At a median of 25 months (range 11-107 months) after SRS, 9 patients developed new or worsened visual field deficits. One patient developed a complete homonymous hemianopia, and 8 patients developed quadrantanopias. The actuarial risk of sustaining a new visual deficit was 3% at 3 years, 5% at 5 years, and 8% at 10 years. Fifteen patients had hemorrhage during the latency period, resulting in death in 9 of the patients. The annual hemorrhage rate during the latency interval was 2%, and no hemorrhages occurred after confirmed obliteration. coNclusioNs Despite an overall treatment mortality of 5%, related to latency interval hemorrhage, SRS was associated with only a 5.6% risk of new visual deficit and a final obliteration rate close to 80% in patients with AVMs of the postgeniculate visual pathway.

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Brain Arteriovenous Malformations

Sahlein¹,

Manning²

2016

Neurovascular Imaging

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Stereotactic Radiosurgery for Arteriovenous Malformations Located in Deep Critical Regions

Cited by 38 publications

References 58 publications

Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

Stereotactic radiosurgery for arteriovenous malformations of the postgeniculate visual pathway

Brain Arteriovenous Malformations

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