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Radiosurgery for large cerebral arteriovenous malformations

  • Clinical Article
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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.

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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.

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Authors and Affiliations

  1. Department of Neurosurgery, Dongguk University College of Medicine, Goyang, Gyeonggi-do, South Korea

    Seung-Yeob Yang

  2. Department of Neurosurgery, Seoul National University College of Medicine, 28 Yeongon-dong, Jongno-gu, Seoul, 110-744, South Korea

    Dong Gyu Kim, Hyun-Tai Chung, Sun Ha Paek & Dae Hee Han

  3. Department of Neurosurgery, Kangwon National University College of Medicine, Chuncheon, Kangwon-do, South Korea

    Jae Hyo Park

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  1. Seung-Yeob Yang
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Comment

Stereotactic radiosurgery for large cerebral arteriovenous malformation

Gamma Knife surgery has been very successfull at treating small to medium sized arteriovenous malformations (AVM’s). Obliteration rates for AVM’s less than 3 cm in maximal diameter are approximately 80 to 85%. However, large AVM`s are less likely to be “cured” by single fraction stereotactically delivered radiosurgery and such treatment is attended by higher complication risks: The authors could demonstrate that preradiosurgical embolization increased significantly the risk of haemorrhage for their nonhaemorrhage subgroup, whereas it had no effect on the haemorrhage subgroup. In addition, latency period haemorrhage occurred significantly more in their embolization subgroup, but in no patient in the nonembolization subgroup.

Large or even giant cerbrovascular formations need therefore special attentions as their clinical behaviour is different from small or medium sized lesions. It is this fact that the makes this study of special interest. The authors results may let us conclude that for large AVMs, multiple embolization procedures may be required to avoid changing blood flow patterns in the brain too rapidly or drastically (1). This may underline that the treatment of brain AVMs can only be greatly enhanced by adopting a team approach utilizing combined modality therapy. Using this strategy, a treatment plan is devised to offer the lowest risk yet highest chance of obliterating the lesion.

References

1. Schaller B, Graf R. Cerebral venous infarction: The pathophysiological concept. Cerebrovasc Dis 2004; 18:179–188

B. Schaller

Stockholm

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Yang, SY., Kim, D.G., Chung, HT. et al. Radiosurgery for large cerebral arteriovenous malformations. Acta Neurochir (Wien) 151, 113–124 (2009). https://doi.org/10.1007/s00701-008-0173-5

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  • DOI: https://doi.org/10.1007/s00701-008-0173-5

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