Advertisement

Acta Neurochirurgica

, Volume 151, Issue 2, pp 113–124 | Cite as

Radiosurgery for large cerebral arteriovenous malformations

  • Seung-Yeob Yang
  • Dong Gyu KimEmail author
  • Hyun-Tai Chung
  • Sun Ha Paek
  • Jae Hyo Park
  • Dae Hee Han
Clinical Article

Abstract

Background

Radiosurgery is an effective treatment option for patients with small to medium sized arteriovenous malformations. However, it is not generally accepted as an effective tool for larger (>14 cm3) arteriovenous malformations because of low obliteration rates. The authors assessed the applicability and effectiveness of radiosurgery for large arteriovenous malformations.

Method

We performed a retrospective study of 46 consecutive patients with more than 14 ml of arteriovenous malformations who were treated with radiosurgery using a linear accelerator and gamma knife (GK). They were grouped according to their initial clinical presentation—17 presented with and 29 without haemorrhage. To assess the effect of embolization, these 46 patients were also regrouped into two subgroups—25 with and 21 without preradiosurgical embolization. Arteriovenous malformations found to have been incompletely obliterated after 3-year follow-up neuroimaging studies were re-treated using a GK.

Findings

The mean treatment volume was 29.5 ml (range, 14.0–65.0) and the mean marginal dose was 14.1 Gy (range, 10.0–20.0). The mean clinical follow-up periods after initial radiosurgery was 78.1 months (range, 34.0–166.4). Depending on the results of the angiography, 11 of 33 patients after the first radiosurgery and three of four patients after the second radiosurgery showed complete obliteration. Twenty patients received the second radiosurgery and their mean volume was significantly smaller than their initial volume (P = 0.017). The annual haemorrhage rate after radiosurgery was 2.9% in the haemorrhage group (mean follow-up 73.3 months) and 3.1% in the nonhaemorrhage group (mean follow-up 66.5 months) (P = 0.941). Preradiosurgical embolization increased the risk of haemorrhage for the nonhaemorrhage group (HR, 28.03; 95% CI, 1.08–6,759.64; P = 0.039), whereas it had no effect on the haemorrhage group. Latency period haemorrhage occurred in eight patients in the embolization group, but in no patient in the nonembolization group (P = 0.004).

Conclusions

Radiosurgery may be a safe and effective arteriovenous malformation treatment method that is worth considering as an alternative treatment option for a large arteriovenous malformation.

Keywords

Arteriovenous malformation Embolization Haemorrhage Obliteration Radiosurgery 

Notes

Acknowledgements

This study was partially supported by grants from the Clinical Research Institute, Seoul National University Hospital and the Korea Brain and Spinal Cord Research Foundation. The funding sources had no role in study design, data collection, data analysis, data interpretation, or writing of the report. We thank Byung Joo Park, M.D. and Medical Research Collaborating Center Seoul National University Hospital for their assistance in our statistical analysis. Moon Hee Han, M.D. helped us to review the neuroradiologic findings of large cerebral arteriovenous malformations.

Conflicts of interest notification

The authors have no conflicts of interest to declare.

References

  1. 1.
    al-Rodhan NR, Sundt TM Jr, Piepgras DG, Nichols DA, Rufenacht D, Stevens LN (1993) Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations. J Neurosurg 78:167–175PubMedGoogle Scholar
  2. 2.
    Batjer HH, Devous MD Sr, Meyer YJ, Purdy PD, Samson DS (1988) Cerebrovascular hemodynamics in arteriovenous malformation complicated by normal perfusion pressure breakthrough. Neurosurgery 22:503–509PubMedGoogle Scholar
  3. 3.
    Brown RD Jr, Wiebers DO, Forbes G, O’Fallon WM, Piepgras DG, Marsh WR, Maciunas RJ (1988) The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68:352–357PubMedGoogle Scholar
  4. 4.
    Castel JP, Kantor G (2001) [Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations. Current data and analysis of recent literature]. Neurochirurgie 47:369–383PubMedGoogle Scholar
  5. 5.
    Chang SD, Shuster DL, Steinberg GK, Levy RP, Frankel K (1997) Stereotactic radiosurgery of arteriovenous malformations: pathologic changes in resected tissue. Clin Neuropathol 16:111–116PubMedGoogle Scholar
  6. 6.
    Colombo F, Pozza F, Chierego G, Casentini L, De Luca G, Francescon P (1994) Linear accelerator radiosurgery of cerebral arteriovenous malformations: an update. Neurosurgery 34:14–20 discussion 20–11PubMedCrossRefGoogle Scholar
  7. 7.
    Ellis TL, Friedman WA, Bova FJ, Kubilis PS, Buatti JM (1998) Analysis of treatment failure after radiosurgery for arteriovenous malformations. J Neurosurg 89:104–110PubMedGoogle Scholar
  8. 8.
    Flickinger JC, Pollock BE, Kondziolka D, Lunsford LD (1996) A dose–response analysis of arteriovenous malformation obliteration after radiosurgery. Int J Radiat Oncol Biol Phys 36:873–879PubMedGoogle Scholar
  9. 9.
    Gobin YP, Laurent A, Merienne L, Schlienger M, Aymard A, Houdart E, Casasco A, Lefkopoulos D, George B, Merland JJ (1996) Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85:19–28PubMedGoogle Scholar
  10. 10.
    Halbach VV, Higashida RT, Hieshima GB, Norman D (1987) Normal perfusion pressure breakthrough occurring during treatment of carotid and vertebral fistulas. AJNR Am J Neuroradiol 8:751–756PubMedGoogle Scholar
  11. 11.
    Han PP, Ponce FA, Spetzler RF (2003) Intention-to-treat analysis of Spetzler–Martin grades IV and V arteriovenous malformations: natural history and treatment paradigm. J Neurosurg 98:3–7PubMedGoogle Scholar
  12. 12.
    Jungreis CA, Horton JA, Hecht ST (1989) Blood pressure changes in feeders to cerebral arteriovenous malformations during therapeutic embolization. AJNR Am J Neuroradiol 10:575–577PubMedGoogle Scholar
  13. 13.
    Karlsson B, Lindquist C, Steiner L (1997) Prediction of obliteration after gamma knife surgery for cerebral arteriovenous malformations. Neurosurgery 40:425–430 discussion 430–421PubMedCrossRefGoogle Scholar
  14. 14.
    Kihlstrom L, Guo WY, Karlsson B, Lindquist C, Lindqvist M (1997) Magnetic resonance imaging of obliterated arteriovenous malformations up to 23 years after radiosurgery. J Neurosurg 86:589–593PubMedGoogle Scholar
  15. 15.
    Kjellberg RN, Hanamura T, Davis KR, Lyons SL, Adams RD (1983) Bragg-peak proton-beam therapy for arteriovenous malformations of the brain. N Engl J Med 309:269–274PubMedGoogle Scholar
  16. 16.
    Kondziolka D, Lunsford LD, Flickinger JC (1993) Gamma knife stereotactic radiosurgery for cerebral vascular malformations. In: Alexander E, Loeffler JS, Lunsford LD (eds) Stereotactic radiosurgery. McGraw-Hill, New York, p 136–146Google Scholar
  17. 17.
    Lindqvist M, Karlsson B, Guo WY, Kihlstrom L, Lippitz B, Yamamoto M (2000) Angiographic long-term follow-up data for arteriovenous malformations previously proven to be obliterated after gamma knife radiosurgery. Neurosurgery 46:803–808 discussion 809–810PubMedCrossRefGoogle Scholar
  18. 18.
    Lindvall P, Bergstrom P, Lofroth PO, Hariz MI, Henriksson R, Jonasson P, Bergenheim AT (2003) Hypofractionated conformal stereotactic radiotherapy for arteriovenous malformations. Neurosurgery 53:1036–1042 discussion 1042–1033PubMedCrossRefGoogle Scholar
  19. 19.
    Major O, Szeifert GT, Kemeny AA (2007) Physiological and pathological observations on rat middle cerebral arteries and human AVM tissue cultures following single high-dose gamma irradiation. Prog Neurol Surg 20:375–387PubMedCrossRefGoogle Scholar
  20. 20.
    Martin NA, Vinters HV (1995) Arteriovenous malformations. In: Carter LF, Spetzler RF, Hamilton MG (eds) Neurovascular surgery. McGraw-Hill, New York, pp 875–903Google Scholar
  21. 21.
    Maruyama K, Kawahara N, Shin M, Tago M, Kishimoto J, Kurita H, Kawamoto S, Morita A, Kirino T (2005) The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med 352:146–153PubMedCrossRefGoogle Scholar
  22. 22.
    Mast H, Young WL, Koennecke HC, Sciacca RR, Osipov A, Pile-Spellman J, Hacein-Bey L, Duong H, Stein BM, Mohr JP (1997) Risk of spontaneous haemorrhage after diagnosis of cerebral arteriovenous malformation. Lancet 350:1065–1068PubMedCrossRefGoogle Scholar
  23. 23.
    Mathis JA, Barr JD, Horton JA, Jungreis CA, Lunsford LD, Kondziolka DS, Vincent D, Pentheny S (1995) The efficacy of particulate embolization combined with stereotactic radiosurgery for treatment of large arteriovenous malformations of the brain. AJNR Am J Neuroradiol 16:299–306PubMedGoogle Scholar
  24. 24.
    Miyawaki L, Dowd C, Wara W, Goldsmith B, Albright N, Gutin P, Halbach V, Hieshima G, Higashida R, Lulu B, Pitts L, Schell M, Smith V, Weaver K, Wilson C, Larson D (1999) Five year results of LINAC radiosurgery for arteriovenous malformations: outcome for large AVMS. Int J Radiat Oncol Biol Phys 44:1089–1106PubMedGoogle Scholar
  25. 25.
    Pan DH, Guo WY, Chung WY, Shiau CY, Chang YC, Wang LW (2000) Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations. J Neurosurg 93(Suppl 3):113–119PubMedGoogle Scholar
  26. 26.
    Paulsen RD, Steinberg GK, Norbash AM, Marcellus ML, Marks MP (1999) Embolization of basal ganglia and thalamic arteriovenous malformations. Neurosurgery 44:991–996 discussion 996–997PubMedCrossRefGoogle Scholar
  27. 27.
    Pollock BE, Flickinger JC (2002) A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:79–85PubMedGoogle Scholar
  28. 28.
    Pollock BE, Flickinger JC, Lunsford LD, Bissonette DJ, Kondziolka D (1996) Hemorrhage risk after stereotactic radiosurgery of cerebral arteriovenous malformations. Neurosurgery 38:652–659 discussion 659–661PubMedCrossRefGoogle Scholar
  29. 29.
    Pollock BE, Gorman DA, Coffey RJ (2003) Patient outcomes after arteriovenous malformation radiosurgical management: results based on a 5- to 14-year follow-up study. Neurosurgery 52:1291–1296 discussion 1296–1297PubMedCrossRefGoogle Scholar
  30. 30.
    Pollock BE, Kline RW, Stafford SL, Foote RL, Schomberg PJ (2000) The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 48:817–824PubMedGoogle Scholar
  31. 31.
    Pollock BE, Kondziolka D, Lunsford LD, Bissonette D, Flickinger JC (1996) Repeat stereotactic radiosurgery of arteriovenous malformations: factors associated with incomplete obliteration. Neurosurgery 38:318–324PubMedCrossRefGoogle Scholar
  32. 32.
    Rauch RA, Vinuela F, Dion J, Duckwiler G, Amos EC, Jordan SE, Martin N, Jensen ME, Bentson J, Thibault L (1992) Preembolization functional evaluation in brain arteriovenous malformations: the superselective Amytal test. AJNR Am J Neuroradiol 13:303–308PubMedGoogle Scholar
  33. 33.
    Redekop G, TerBrugge K, Montanera W, Willinsky R (1998) Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage. J Neurosurg 89:539–546PubMedGoogle Scholar
  34. 34.
    Schneider BF, Eberhard DA, Steiner LE (1997) Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 87:352–357PubMedGoogle Scholar
  35. 35.
    Sirin S, Kondziolka D, Niranjan A, Flickinger JC, Maitz AH, Lunsford LD (2006) Prospective staged volume radiosurgery for large arteriovenous malformations: indications and outcomes in otherwise untreatable patients. Neurosurgery 58:17–27 discussion 17–27PubMedCrossRefGoogle Scholar
  36. 36.
    Sorimachi T, Takeuchi S, Koike T, Minakawa T, Abe H, Tanaka R (1995) Blood pressure monitoring in feeding arteries of cerebral arteriovenous malformations during embolization: a preventive role in hemodynamic complications. Neurosurgery 37:1041–1047 discussion 1047–1048PubMedCrossRefGoogle Scholar
  37. 37.
    Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483PubMedCrossRefGoogle Scholar
  38. 38.
    Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, Pile-Spellman J, Mohr JP (2006) Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 66:1350–1355PubMedCrossRefGoogle Scholar
  39. 39.
    Taylor CL, Dutton K, Rappard G, Pride GL, Replogle R, Purdy PD, White J, Giller C, Kopitnik TA Jr, Samson DS (2004) Complications of preoperative embolization of cerebral arteriovenous malformations. J Neurosurg 100:810–812PubMedGoogle Scholar
  40. 40.
    Touboul E, Al Halabi A, Buffat L, Merienne L, Huart J, Schlienger M, Lefkopoulos D, Mammar H, Missir O, Meder JF, Laurent A, Housset M (1998) Single-fraction stereotactic radiotherapy: a dose–response analysis of arteriovenous malformation obliteration. Int J Radiat Oncol Biol Phys 41:855–861PubMedGoogle Scholar
  41. 41.
    Vernimmen FJ, Slabbert JP, Wilson JA, Fredericks S, Melvill R (2005) Stereotactic proton beam therapy for intracranial arteriovenous malformations. Int J Radiat Oncol Biol Phys 62:44–52PubMedCrossRefGoogle Scholar
  42. 42.
    Veznedaroglu E, Andrews DW, Benitez RP, Downes MB, Werner-Wasik M, Rosenstock J, Curran WJ Jr, Rosenwasser RH (2004) Fractionated stereotactic radiotherapy for the treatment of large arteriovenous malformations with or without previous partial embolization. Neurosurgery 55:519–530 discussion 530–511PubMedCrossRefGoogle Scholar
  43. 43.
    Young WL, Kader A, Pile-Spellman J, Ornstein E, Stein BM (1994) Arteriovenous malformation draining vein physiology and determinants of transnidal pressure gradients. The Columbia University AVM Study Project. Neurosurgery 35:389–395 discussion 395–386PubMedCrossRefGoogle Scholar
  44. 44.
    Zabel-du Bois A, Milker-Zabel S, Huber P, Schlegel W, Debus J (2006) Linac-based radiosurgery or hypofractionated stereotactic radiotherapy in the treatment of large cerebral arteriovenous malformations. Int J Radiat Oncol Biol Phys 64:1049–1054PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Seung-Yeob Yang
    • 1
  • Dong Gyu Kim
    • 2
    Email author
  • Hyun-Tai Chung
    • 2
  • Sun Ha Paek
    • 2
  • Jae Hyo Park
    • 3
  • Dae Hee Han
    • 2
  1. 1.Department of NeurosurgeryDongguk University College of MedicineGoyangSouth Korea
  2. 2.Department of NeurosurgerySeoul National University College of MedicineSeoulSouth Korea
  3. 3.Department of NeurosurgeryKangwon National University College of MedicineChuncheonSouth Korea

Personalised recommendations