Management of Residual Brain Arteriovenous Malformations After Stereotactic Radiosurgery

Stéphanie Lenck; Michael Schwartz; Jin Hengwei; Ronit Agid; Patrick Nicholson; Timo Krings; Michael Tymianski; Vitor Mendes-Pereira; Ivan Radovanovic

doi:10.1016/j.wneu.2018.05.180

Management of Residual Brain Arteriovenous Malformations After Stereotactic Radiosurgery

World Neurosurg. 2018 Aug:116:e1105-e1113. doi: 10.1016/j.wneu.2018.05.180. Epub 2018 Jun 1.

Authors

Stéphanie Lenck¹, Michael Schwartz², Jin Hengwei³, Ronit Agid¹, Patrick Nicholson¹, Timo Krings¹, Michael Tymianski⁴, Vitor Mendes-Pereira⁵, Ivan Radovanovic⁶

Affiliations

¹ Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
² Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
³ Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
⁴ Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
⁵ Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
⁶ Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address: Ivan.Radovanovic@uhn.ca.

PMID: 29864564
DOI: 10.1016/j.wneu.2018.05.180

Abstract

Objective: To assess outcome of residual brain arteriovenous malformation (BAVM) after stereotactic radiosurgery.

Methods: Patients with residual BAVM 3 years after radiosurgery were retrospectively included. Demographics, angioarchitectural characteristics, complications, bleeding, and cure rates of patients with intervention or conservative management (i.e., observation) were compared. We analyzed characteristics of patients treated conservatively who achieved cure or still had persistent BAVMs during follow-up.

Results: The study included 87 patients including 5 patients with subtotal obliteration with a mean follow-up time of 33.7 ± 36.6 months. Of patients, 27 (31.0%) received subsequent treatment (radiosurgery, n = 23; microsurgery, n = 3; embolization, n = 1), and 60 (69%) were treated conservatively. After repeat SRS, 4 (14.8%) patients experienced symptomatic complications after the second treatment, and 7 (25.9%) experienced asymptomatic changes. Three (3.4%) patients, all of whom presented initially with a ruptured BAVM, experienced hemorrhage during follow-up. Subsequent treatment was effective with a complete cure of BAVM in 11 patients (40.7%). Complete resolution of the residual BAVM occurred in 15 (25%) patients treated conservatively.

Conclusions: Complete obliteration of a significant number of residual BAVMs may occur 3-5 years after the first irradiation, whereas increased radiation dose associated with repeat SRS may lead to an increased risk of complications. The fact that the interval risk of bleeding decreased after SRS (especially for ruptured BAVM) lends further strength to the argument for a conservative management approach for residual BAVM 3-5 years after the first irradiation.

Keywords: Brain arteriovenous malformations; Radiosurgery; Residual brain AVM.

MeSH terms

Adult
Aged
Brain / surgery*
Cerebral Angiography / methods
Conservative Treatment
Embolization, Therapeutic*
Female
Follow-Up Studies
Humans
Intracranial Arteriovenous Malformations / surgery*
Male
Middle Aged
Radiosurgery* / adverse effects
Retrospective Studies
Treatment Outcome