Chapter-094 Stereotactic Radiosurgery for Cerebral AVMS

OBJECTIVE Microsurgical resection of arteriovenous malformations (AVMs) can be aided by staged treatment consisting of stereotactic radiosurgery followed by resection in a delayed fashion. This approach is particularly useful for high Spetzler-Martin (SM) grade lesions because radiosurgery can reduce flow through the AVM, downgrade the SM rating, and induce histopathological changes that additively render the AVM more manageable for resection. The authors present their 28-year experience in managing AVMs with adjunctive radiosurgery followed by resection. METHODS The authors retrospectively reviewed records of patients treated for cerebral AVMs at their institution between January 1990 and August 2019. All patients who underwent stereotactic radiosurgery (with or without embolization), followed by resection, were included in the study. Of 1245 patients, 95 met the eligibility criteria. Univariate and multivariate regression analyses were performed to assess relationships between key variables and clinical outcomes. RESULTS The majority of lesions treated (53.9%) were high grade (SM grade IV–V), 31.5% were intermediate (SM grade III), and 16.6% were low grade (SM grade I–II). Hemorrhage was the initial presenting sign in half of all patients (49.5%). Complete resection was achieved among 84% of patients, whereas 16% had partial resection, the majority of whom received additional radiosurgery. Modified Rankin Scale (mRS) scores of 0–2 were achieved in 79.8% of patients, and 20.2% had poor (mRS scores 3–6) outcomes. Improved (44.8%) or stable (19%) mRS scores were observed among 63.8% of patients, whereas 36.2% had a decline in mRS scores. This includes 22 patients (23.4%) with AVM hemorrhage and 6 deaths (6.7%) outside the perioperative period but prior to AVM obliteration. CONCLUSIONS Stereotactic radiosurgery is a useful adjunct in the presurgical management of cerebral AVMs. Multimodal therapy allowed for high rates of AVM obliteration and acceptable morbidity rates, despite the predominance of high-grade lesions in this series of patients.

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Abstract TP490: Long Term Clinical Results of Linear Accelerator Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Single Institution Experience of 18 Years

Stroke ◽

10.1161/str.51.suppl_1.tp490 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Yung Ki Park ◽

Hae-Won Koo

Keyword(s):

Adverse Event ◽

Radiation Dose ◽

Stereotactic Radiosurgery ◽

Linear Accelerator ◽

Clinical Results ◽

Single Institution ◽

High Radiation ◽

Cerebral Avms

Introduction: Cerebral arteriovenous malformation (AVM) is an intracranial pial vascular lesion which is treated with microsurgery, endovascular treatment or stereotactic radiosurgery (SRS). We introduce the long-term clinical results of linear accelerator (LINAC) stereotactic radiosurgery for cerebral AVM which is treated in single institution for 18 years period. Methods: Retrospective chart review was held in cerebral AVM patients treated with Novalis (BrainLAB AG, Heimstetten, Germany) stereotactic radiotherapy from 2001 to 2018. Clinical results such as obliteration rate, hemorrhage rate after SRS, and radiosurgery related adverse event was analyzed. Furthermore, predictors for obliteration and symptomatic radiosurgery induced adverse event was analyzed with multivariate logistic regression test. Results: Among 117 patients with cerebral AVMs treated with LINAC-based SRS, 72 were included in study. Total obliteration rate was 80.6% (58/72) for mean 57.0±48.3 months follow up period. Post-SRS hemorrhage and mortality rate was 6.9% (4/72) and 1.4% (1/72), respectively. Mean radiation dose and volume was 22.8Gy and 3.7cc, respectively. Independent predictive factors for nidus obliteration was: (1) radiation dose (OR 1.43, 95% CI 1.04-2.08, p=0.0374), (2) Ruptured AVM (OR 12.18, 95% CI 2.38-86.47, p=0.0054), (3) Virginia AVM score (OR 0.21, 95% CI 0.07-0.53, p=0.0028), and (4) follow up period months (OR 1.03, 95% CI 1.01-1.06, p=0.0261). Independent risk factors for symptomatic radiosurgery related adverse event was radiation volume (OR 1.61, 95% CI 1.09-2.65, p=0.0326). Conclusion: LINAC-based SRS is effective and relatively safe method for treatment of cerebral AVMs. Independent predictive factors for obliteration was high radiation dosage, ruptured status, low Virginia AVM score, and long follow up period. High radiation volume was related to symptomatic radiation induced adverse event.

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Hypofractionated Stereotactic Radiosurgery for Cerebral AVMs: A Preliminary Report on Bleeding Risk and Obliteration Rate

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2011.06.1890 ◽

2011 ◽

Vol 81 (2) ◽

pp. S638

Author(s):

S.C. Blamek ◽

D. Larysz ◽

L. Miszczyk ◽

A. Rudnik ◽

A. Idasiak ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Preliminary Report ◽

Bleeding Risk ◽

Obliteration Rate ◽

Cerebral Avms ◽

Hypofractionated Stereotactic Radiosurgery

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Chapter-91 Stereotactic Radiosurgery for Cerebral AVMs

Ramamurthi and Tandon�s Manual of Neurosurgery ◽

10.5005/jp/books/12212_201 ◽

2014 ◽

pp. 672-676

Author(s):

Ganapathy K

Keyword(s):

Stereotactic Radiosurgery ◽

Cerebral Avms

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Stereotactic radiosurgery of intracranial arteriovenous malformations and the use of the K index in determining treatment dose

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14157 ◽

2014 ◽

Vol 37 (3) ◽

pp. E15 ◽

Cited By ~ 4

Author(s):

Symeon Missios ◽

Kimon Bekelis ◽

Gasser Al-Shyal ◽

Peter A. Rasmussen ◽

Gene H. Barnett

Keyword(s):

Stereotactic Radiosurgery ◽

Gamma Knife ◽

Arteriovenous Malformations ◽

Univariate Analysis ◽

Gamma Knife Radiosurgery ◽

Maximum Diameter ◽

Obliteration Rate ◽

K Index ◽

Kaplan Meier ◽

Cerebral Avms

Object The appropriate dose during stereotactic radiosurgery (SRS) of cerebral arteriovenous malformations (AVMs) remains a matter of debate. In the present study, the authors retrospectively evaluated the association of using a prescribed dose calculated utilizing the K index with the obliteration rate of cerebral AVMs after SRS. Methods The authors performed a retrospective analysis of the Cleveland Clinic SRS database. All patients undergoing Gamma Knife radiosurgery for cerebral AVMs from 1997 to 2010 were selected. Regression techniques and Kaplan-Meier analyses were used to investigate the effect of divergence from the optimal K index dose on the rate of AVM obliteration. Results In the study period 152 patients (mean age 43.6 years; 53.9% of treatments were performed in females) underwent 165 Gamma Knife radiosurgery treatments for AVMs. In a univariate analysis Spetzler-Martin grade (OR 0.63 [95% CI 0.42–0.93]), higher AVM score (OR 0.43 [95% CI 0.27–0.70]), larger AVM volume (OR 0.88 [95% CI 0.82–0.94]), and higher maximum diameter (OR 0.56 [95% CI 0.41–0.77]) were associated with a lower rate of AVM obliteration. Higher margin dose (OR 1.16 [95% CI 1.08–1.24]) and higher maximum dose (OR 1.08 [95% CI 1.04–1.13]) were associated with a higher obliteration rate. To further examine the effect of prescribed dose divergence from the calculated K index dose, cases were classified to groups depending on the AVM volume and dose variance from the ideal K index dose. Contingency tables and Kaplan-Meier curves were then created, and no significant differences in rates of obliteration were noted among the different groups. Conclusions Gamma Knife radiosurgery for cerebral AVMs remains an effective and safe treatment modality. Smaller AVMs may receive doses less than the calculated K index dose without an apparent effect on obliteration rates.

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Abstract TMP118: Clinical Outcomes of Surgical Resection After Stereotactic Radiosurgery Among Patients With Cerebral Arteriovenous Malformations

Stroke ◽

10.1161/str.51.suppl_1.tmp118 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mark G Bigder ◽

Omar Choudhri ◽

Mihir Gupta ◽

Ephraim Church ◽

Steven Chang ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Perioperative Period ◽

Multivariate Regression Analysis ◽

Low Grade ◽

High Grade ◽

Eligibility Criteria ◽

Cerebral Avms

Introduction: Surgical treatment of arteriovenous malformations (AVMs), particularly higher grade lesions, can be aided by staged treatment consisting of stereotactic radiosurgery (SRS) followed by surgical resection in a delayed fashion. This strategy can be used to downgrade the AVM S-M grade, reduce blood flow through the AVM and often results in histopathological changes making AVMs more amenable to microsurgical resection. We present our 28-year clinical experience in managing AVMs with pre-operative SRS as a surgical adjunct. Methods: We retrospectively reviewed and analyzed records of all patients treated for cerebral AVMs between February 1991 and July 2019 at our institution. All patients that underwent SRS, with and without embolization, followed by microsurgery were included in the study. Of the 1245 cerebral AVM patients treated at our institution, 62 patients met eligibility criteria. Univariate and multivariate regression analysis was performed where appropriate to examine relationships between key variables and outcomes. Results: The majority of lesions (50%) were high grade (SM 4-5), 28.6% were intermediate (SM 3), while 21.4% were low grade (SM 1-2). Hemorrhage was the presenting sign among 22.6% of patients. Complete resection was achieved among 64.5%, 79% and 82% of patients after first, second and third surgical stages respectively; 16.1% of patients had partial resection requiring further treatment. Radiographic cure was achieved among 53 patients (85.5%), while 8 (12.9%) patients had residual AVM at last follow up. Six of 8 patients without radiographic cure received post-operative SRS. Thirty-seven patients (63.8%) had improved (26, 44.8%) or stable mRS scores (11, 19%), while 21 (36.2%) had a decline in mRS at final follow up compared to mRS at presentation; this includes 4 (6.9%) deaths due to hemorrhage, outside of the perioperative period, but occurring during follow up prior to AVM obliteration. Conclusion: SRS is a useful adjunct in the surgical management of cerebral AVMs. Multimodal therapy allowed for high obliteration rates with acceptable morbidity in this series of patients with predominantly high grade AVMs.

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Seizure outcomes after stereotactic radiosurgery for the treatment of cerebral arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2015.12.jns152461 ◽

2017 ◽

Vol 126 (3) ◽

pp. 845-851 ◽

Cited By ~ 11

Author(s):

Benjamin J. Ditty ◽

Nidal B. Omar ◽

Paul M. Foreman ◽

Joseph H. Miller ◽

Kimberly P. Kicielinski ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Arteriovenous Malformations ◽

Case Series ◽

Seizure Outcome ◽

Cerebral Arteriovenous Malformations ◽

Surgery Outcome ◽

Number Of Patients ◽

Cerebral Avms

OBJECTIVE Patients with cerebral arteriovenous malformations (AVMs) commonly present with seizure. Seizure outcomes in patients treated with stereotactic radiosurgery (SRS) are poorly defined. A case series of patients with cerebral AVMs treated with SRS is presented to evaluate long-term seizure outcome. METHODS A retrospective review of the medical record was performed, identifying 204 consecutive patients with AVMs treated with SRS between January 1991 and June 2012. Clinical and radiographic data were evaluated. Seizure outcome was measured using the Engel Epilepsy Surgery Outcome Scale. Mean duration of follow-up was 37.1 months (SD 38.3 months) with a minimum follow-up period of 1 month. RESULTS Of the 204 patients with cerebral AVMs treated with SRS, 78 patients (38.2%) presented with seizures and 49 of those patients were treated with antiepileptic drugs (AEDs). Following SRS, 63 (80.8%) of the 78 patients who had had seizures prior to SRS were seizure-free at a mean follow-up time of 37.2 months (SD 41.3 months). Of the 49 patients who had been treated with AEDs, 17 were still taking AEDs at last follow-up. Of the 126 patients who did not present with seizures prior to treatment with SRS, only 5 patients (4.0%) had seizures in the post-SRS period. There was no significant correlation between post-SRS seizure status and patient demographic features, comorbidities, AVM characteristics, history of operative intervention, pre- or posttreatment hemorrhage, or radiographic degree of AVM resolution. CONCLUSIONS Stereotactic radiosurgery for treatment of cerebral AVMs is effective at providing long-term control of seizures. A substantial number of patients who were treated with SRS were not only seizure free at their last follow-up, but had been successfully weaned from antiepileptic medications.

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