Long-term Outcomes With Planned Multistage Reduced Dose Repeat Stereotactic Radiosurgery for Treatment of Inoperable High-Grade Arteriovenous Malformations: An Observational Retrospective Cohort Study. Issue 1 (14th February 2017)

• Record Type: Journal Article
• Authors: Marciscano, Ariel E.; Huang, Judy; Tamargo, Rafael J.; Hu, Chen; Khattab, Mohamed H.; Aggarwal, Sameer; Lim, Michael; Redmond, Kristin J.; Rigamonti, Daniele; Kleinberg, Lawrence R.
• Is Part Of: Neurosurgery. Volume 81:Issue 1(2017)
• Page Start: 136
• Page End: 146
• Publication Date: 2017-02-14
• Subjects: AVM -- Cerebral arteriovenous malformation -- Inoperable high-grade AVM -- Multistage SRS -- Stereotactic radiosurgery; Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyw041
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: BACKGROUND: There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). OBJECTIVE: To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs. METHODS: Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected. RESULTS: Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated ( P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year. CONCLUSION: Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.