Stereotactic Radiosurgery for Arteriovenous Malformations Located in Deep Critical Regions

• Published in: Neurosurgery Vol. 70; no. 6; pp. 1458 - 1471
• Main Authors: Nagy, Gábor, Major, Ottó, Rowe, Jeremy G., Radatz, Matthias W.R., Hodgson, Timothy J., Coley, Stuart C., Kemeny, Andras A.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Oxford University Press 01.06.2012; Lippincott Williams & Wilkins; Wolters Kluwer Health, Inc
• Subjects: Adolescent; Adult; Aged; Arteriovenous Fistula - pathology; Arteriovenous Fistula - surgery; Biological and medical sciences; Child; Child, Preschool; Female; Humans; Infant; Intracranial Arteriovenous Malformations - pathology; Intracranial Arteriovenous Malformations - surgery; Male; Medical sciences; Middle Aged; Morbidity; Neurosurgery; Postoperative Complications - epidemiology; Radiosurgery - adverse effects; Retrospective Studies; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Treatment Outcome; Young Adult; Thalamus/basal ganglia; Arteriovenous malformation; Brainstem; Radiosurgery; Vascular disease; Nervous system diseases; Surgery; Cardiovascular disease; Stereotaxia; Thalamus; Basal ganglion; Congenital disease
• ISSN: 0148-396X; 1524-4040
• DOI: 10.1227/NEU.0b013e318246a4d0

Abstract BACKGROUND: Radiosurgery is widely used to treat deep eloquent arteriovenous malformations (AVMs). OBJECTIVE: To evaluate how anatomic location, AVM size, and treatment parameters define outcome. METHODS: Retrospective analysis of 356 thalamic/basal ganglia and 160 brainstem AVMs treated with gamma knife radiosurgery. RESULTS: Median volume was 2 cm3 (range, 0.02–50) for supratentorial and 0.5 cm3 (range, 0.01–40) for brainstem AVMs; the marginal treatment doses were 17.5 to 25 Gy. After single treatment, obliteration was achieved in 65% of the brainstem, in 69% of the supratentorial, and 40% of the peritectal AVMs. Obliteration of lesions <4 cm3 was better in the brainstem (70%) and in the supratentorium (80%), but not in the peritectal region (40%). Complications were rare (6%–15%) and mild (⩽modified Rankin scale [MRS] 2). Rebleed rate increased with size, but was not higher than before treatment. AVMs >4 cm3 in the brainstem were treated with unacceptable morbidity and low cure rate. Obliteration of large supratentorial AVMs was 65% to 47% with more complications ≥MRS3. Repeat radiosurgical treatment led to obliteration in 66% of the cases with minor morbidity. CONCLUSION: Deep eloquent AVMs <4 cm3 can be treated safely and effectively with radiosurgery. Obliteration of peritectal AVMs is significantly lower after a single treatment. However, morbidity is low, and repeat treatment leads to good obliteration. Radiosurgical treatment >4 cm3 in the brainstem is not recommended. Supratentorial deep AVMs >8 cm3 can be treated with radiosurgery with higher risk and lower obliteration rate. However, these lesions are difficult to treat with other treatment modalities, and a 50% success rate makes radiosurgery a good alternative even in this challenging group.