Abstract
Currently, most radiotherapies for brain arteriovenous malformations (AVMs) are performed as stereotactic single-session irradiations with Gamma Knife or CyberKnife units. An alternative is hypofractionated multi-session treatment with a linear accelerator. This treatment strategy provides theoretical advantages, particularly for AVMs with a diameter > 3 cm, because hypofractionated irradiation allows for the application of high radiation dosages to large target volumes.
A 35-year-old woman presented with recurrent dysesthesias of her left lower leg. An MRI examination revealed an incidental AVM in the left sensorimotor cortex. The maximum diameter was 3.5 cm, and the target volume was 37.5 cm3. Both embolization and microsurgical excision were considered hazardous, given the location of the AVM nidus between the pre- and postcentral gyrus. Despite the large draining vein, which suggested a macrofistulous arteriovenous connection, the nidus of the AVM appeared predominantly “plexiform” (i.e., consisting of small caliber vessels). A single fistula on the mediocaudal aspect of the nidus was suspected. This angioarchitecture, as verified by MRI and DSA, suggested that the AVM should be amenable to radiation therapy. Stereotactic Gamma Knife, CyberKnife, and fractionated linear accelerator (LINAC) irradiation modalities were considered. Fractionated LINAC treatment was favored because of its higher radiation dosage. CT and MRI examinations under stereotactic conditions (with an external Plexiglas frame mounted to the head) were used to define the target volume. A total of 39 Gy was applied in eight sessions (each with 4.875 Gy) on consecutive days. Follow-up MRI examinations after 8, 19, and 31 months demonstrated the progressive obliteration of the AVM nidus. DSA 3 years after the irradiation confirmed the exclusion of the AVM from brain circulation. The patient experienced focal epileptic seizures during the latency phase between stereotactic irradiation and nidus obliteration, which were controlled with lamotrigine. The treatment of brain AVMs with stereotactic hypofractionated LINAC irradiation is the main topic of this chapter.
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Cimpoca, A., Khanafer, A., Henkes, H., Cohen, J.E., Ganslandt, O. (2023). Unruptured AVM of the Sensorimotor Cortex: Fractionated Stereotactic Linear Acceleration Irradiation with Obliteration of the AVM Nidus After 3 Years with Excellent Clinical Outcome. In: Henkes, H., Lylyk, P., Ganslandt, O., Cohen, J.E. (eds) The Arteriovenous Malformations and Fistulas Casebook. Springer, Cham. https://doi.org/10.1007/978-3-030-51200-2_47-1
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DOI: https://doi.org/10.1007/978-3-030-51200-2_47-1
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