Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort

Abstract

OBJECTIVE In this multicenter study, the authors reviewed the results following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs), determined predictors of outcome, and assessed predictive value of commonly used grading scales based upon this large cohort with long-term follow-up. METHODS Data from a cohort of 2236 patients undergoing GKRS for cerebral AVMs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and AVM characteristics were assessed to determine predictors of outcome, and commonly used grading scales were assessed. RESULTS The mean maximum AVM diameter was 2.3 cm, with a mean volume of 4.3 cm. A mean margin dose of 20.5 Gy was delivered. Mean follow-up was 7 years (range 1-20 years). Overall obliteration was 64.7%. Post-GRKS hemorrhage occurred in 165 patients (annual risk 1.1%). Radiation-induced imaging changes occurred in 29.2%; 9.7% were symptomatic, and 2.7% had permanent deficits. Favorable outcome was achieved in 60.3% of patients. Patients with prior nidal embolization (OR 2.1, p < 0.001), prior AVM hemorrhage (OR 1.3, p = 0.007), eloquent location (OR 1.3, p = 0.029), higher volume (OR 1.01, p < 0.001), lower margin dose (OR 0.9, p < 0.001), and more isocenters (OR 1.1, p = 0.011) were more likely to have unfavorable outcomes in multivariate analysis. The Spetzler-Martin grade and radiosurgery-based AVM score predicted outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment. CONCLUSIONS GKRS for cerebral AVMs achieves obliteration and avoids permanent complications in the majority of patients. Patient, AVM, and treatment parameters can be used to predict long-term outcomes following radiosurgery.

Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm

“…Ding et al reported hemorrhage rates of 1.6% in unruptured and 2.0% in ruptured BAVMs; pre-SRS embolization was not significantly associated with post-SRS hemorrhage 33 34. Starke et al reported an overall post-SRS hemorrhage rate of 1.1% 35. Kano et al reported annual rates of post-SRS hemorrhage of 5.5% during years 0–3 and 2.8% during years 3–6 17.…”

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

“…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).…”

Letter to the Editor. Chronic subdural hematoma management and outcomes

“…To this end, multicenter cohort studies and prospective registries, such as those conducted by the International Gamma Knife Research Foundation (IGKRF) and the AANS and ASTRO SRS registries, may yield more reliable findings than systematic reviews and meta-analyses. [3][4][5][6][7]20,[23][24][25] Adeel Ilyas, MD Phoenix, AZ 4 Taipei Veterans General Hospital, Taipei, Taiwan TO THE EDITOR: It was a great pleasure to read the article by Ilyas et al, 3 which pooled the data to compare the effects of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) in patients with large brain arteriovenous malformations (AVMs) (Ilyas A, Chen CJ, Ding D, et al: Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review. J Neurosurg 128:154-164, January 2018).…”

“…Unfortunately, some degree of overlap is typically unavoidable in systematic reviews, where access to individual patient data is limited. 1,16,17,22,25 Furthermore, the degree of overlap cannot be fully quantified. Thus, the effects of including potentially overlapping articles on the results are difficult to predict.…”