Does hemorrhagic presentation in cerebral arteriovenous malformations affect obliteration rate after gamma knife radiosurgery?

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

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P03.08 Large cerebral arteriovenous malformations management with Volume-staged gamma knife radiosurgery

Neuro-Oncology ◽

10.1093/neuonc/noz126.089 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii26-iii26

Author(s):

R M Emad Eldin ◽

W A Reda ◽

A M El-Shehaby ◽

K Abdel Karim ◽

A Nabeel ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Cerebral Arteriovenous Malformations ◽

Factors Affecting ◽

Prescription Dose ◽

The Mean ◽

Cerebral Avms ◽

Grade 3

Abstract BACKGROUND Large cerebral arteriovenous malformations (AVM) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged gamma knife radiosurgery (VSGR) has been developed for the treatment of large AVMs, to increase the efficacy and improve safety of treatment of these lesions. The aim of the study was to assess the efficacy and safety of VSGR technique for the treatment of large cerebral AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All cases had large AVMs (>10 cc). These were 29 patients. RESULTS Twenty-four patients completed radiographic follow up with 15 obliteration cases (62.5%). There was a total of 56 sessions performed. The mean AVM volume was 16 cc (10.1–29.3 cc). The mean prescription dose was 18 Gy (14–22 Gy). The mean follow up duration was 43 months (21–73 months). One patient died during follow up from unrelated cause. Two cases suffered haemorrhage during follow up. Symptomatic edema developed in 5 (17%) patients. The factors affecting obliteration were smaller total volume, higher dose/stage, non-deep location, compact AVM, AVM score less than 3, >18 Gy dose and <15 cc total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (p 0.012). T2 image changes were affected by SM grade 3 or more (p 0.013) and AVM score 3 or more (p 0.014). CONCLUSION VSGR provides an effective and safe treatment option for large cerebral AVMs. Smaller AVM volume is associated with higher obliteration rate.

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Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015332 ◽

2019 ◽

Vol 12 (4) ◽

pp. 401-406

Author(s):

Dorian Hirschmann ◽

Philipp Goebl ◽

Frederic H Witte ◽

Brigitte Gatterbauer ◽

Wei-Te Wang ◽

...

Keyword(s):

Median Time ◽

Gamma Knife ◽

Arteriovenous Malformations ◽

Combined Therapy ◽

Combined Treatment ◽

Gamma Knife Radiosurgery ◽

Effective Treatment Option ◽

Obliteration Rate ◽

Cerebral Avms ◽

Modern Era

BackgroundGamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed.ObjectiveTo present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs.MethodsOverall, 516 patients received radiosurgery for cerebral AVMs between 1992 and 2018 at our department, of whom 265 received radiosurgery alone and 207 were treated with a combined endovascular-radiosurgical approach. Moreover, 45 patients were treated with a volume-staged approach. Two eras were analyzed, the pre-modern era between 1992 and 2002 and the modern era thereafter.ResultsIn GKRS-only treated patients, median time to nidus occlusion was 3.8 years. Spetzler–Ponce (SP) class was a significant predictor for time to obliteration in the whole sample. Median time to obliteration for the combined treatment group was 6.5 years. Patients in the pre-modern era had a significantly higher obliteration rate than those treated in the modern era. Overall, the calculated yearly hemorrhage risk in the observation period after first GKRS was 1.3%. Permanent post-radiosurgical complications occurred in 4.9% of cases but did not differ between the treatment groups or treatment eras. The obliteration rate was significantly lower and the hemorrhage rate was higher in volume-staged treated patients than in conventionally treated patients.ConclusionGKRS is an effective treatment option for SP class A and B cerebral AVMs. After combined endovascular-radiosurgical treatment, the outcome of selected SP class C AVMs aligns with that of SP class B lesions. Both the combined therapy and radiosurgery alone constitute sound methods for treatment of cerebral AVMs.

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Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

Surgery for Cerebral Stroke ◽

10.2335/scs1987.27.4_241 ◽

1999 ◽

Vol 27 (4) ◽

pp. 241-247 ◽

Cited By ~ 1

Author(s):

Masaaki YAMAMOTO ◽

Takayuki TANAKA ◽

Nagatoshi BOKU ◽

Seiji FUKUOKA ◽

Hiromichi HOSODA ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Cerebral Arteriovenous Malformations

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Combined Embolization and Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

Acta Radiologica ◽

10.1177/028418519303400614 ◽

1993 ◽

Vol 34 (6) ◽

pp. 600-606 ◽

Cited By ~ 28

Author(s):

W. Y. Guo ◽

G. Wikholm ◽

B. Karlsson ◽

C. Lindquist ◽

P. Svendsen ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Combined Treatment ◽

Time Lag ◽

Gamma Knife Radiosurgery ◽

Cerebral Arteriovenous Malformations ◽

Neurologic Deficits ◽

Feeding Vessels ◽

Grade Iii

In a study of 46 patients with cerebral arteriovenous malformations (AVMs) the value of combining embolization and gamma knife radiosurgery was assessed. In 35 patients with large grade III to V AVMs (Spetzler-Martin system) staged combined treatment was planned. In 11 patients, radiosurgery complemented embolization for a residual AVM. The number of embolization sessions ranged from 1 to 7 (median 2). Twenty-six patients needed multiple embolization sessions. In 28 patients the grade of AVMs decreased as a result of embolization. In 16 patients collateral feeding vessels developed after embolization which made delineation of the residual nidus difficult. The time lag between the last embolization and radiosurgery ranged from 1 to 24 months (median 4). Nineteen of 35 large grade III to V AVMs were possible to treat by radiosurgery following embolization. In the 46 patients complications occurred in 9 from embolization and in 2 from radiosurgery. Two patients had transient and 9 had permanent neurologic deficits. It is concluded that embolization facilitates radiosurgery for some large AVMs and therefore this combined treatment has a role in the management of AVMs.

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