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Ischemic Stroke
Original research
Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades
  1. Dorian Hirschmann1,
  2. Philipp Goebl1,
  3. Frederic H Witte1,
  4. Brigitte Gatterbauer1,
  5. Wei-Te Wang1,
  6. Philippe Dodier1,
  7. Gerhard Bavinzski1,
  8. Adolf Ertl1,
  9. Wolfgang Marik2,
  10. Ammar Mallouhi2,
  11. Thomas Roetzer3,
  12. Christian Dorfer1,
  13. Wilhelm Eisner4,
  14. Andreas Gruber5,
  15. Klaus Kitz1,
  16. Josa M Frischer1
  1. 1 Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
  2. 2 Department of Radiology, Medical University of Vienna, Vienna, Austria
  3. 3 Institute of Neurology, Medical University of Vienna, Vienna, Austria
  4. 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
  5. 5 Department of Neurosurgery, Johannes Kepler Universitat Linz, Linz, Austria
  1. Correspondence to Associate Professor Josa M Frischer, Department of Neurosurgery, Medical University of Vienna, 1090 Wien, Austria; josa.frischer{at}meduniwien.ac.at

Abstract

Background Gamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed.

Objective To present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs.

Methods Overall, 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.

Results In 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.

Conclusion GKRS 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.

  • arteriovenous malformation
  • vascular malformation
  • brain
  • hemorrhage

http://dx.doi.org/10.1136/neurintsurg-2019-015332

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    Footnotes

    • Contributors DH: Substantial contributions to the acquisition, analysis and interpretation of data, drafting the work, and final approval of the version to be published. PG, FHW: Substantial contributions to the acquisition and analysis of data, revising the work critically for important intellectual content, and final approval of the version to be published. BG, W-TW, PD, GB, AE, WM, AM, TR, CD, WE, AG, KK: Substantial contributions to the acquisition of data, revising the work critically for important intellectual content, and final approval of the version to be published. JMF: Substantial contributions to the conception and design of the work, acquisition, analysis and interpretation of data, drafting the work, and final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding This work was supported by the Medical Scientific Fund of the Mayor of the City of Vienna, Project Nr. 18096.

    • Competing interests None declared.

    • Ethics approval Ethical review committee of the Medical University of Vienna (EK 1392/2018).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Individual de-identified participant data will not be shared due to the General Data Protection Regulation which came into effect on 25 May 2018 in Austria. The study protocol in German language will be available on request.

    • Presented at Portions of this work were presented as oral presentations at the Meeting of the Section of Functional Neurosurgery and Radiosurgery of the Austrian Society of Neurosurgeons, 4-5 May 2018, Vienna, Austria and the Meeting of the Section of Cerebrovascular Neurosurgery of the Austrian Society of Neurosurgeons, 10-11 May 2019, Salzburg, Austria.

    • Patient consent for publication Not required.