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  • Outcomes of Ruptured Intracranial Arteriovenous Malformations Treated with Gamma Knife Radiosurgery

    Final Number:

    Dale Ding MD; Chun-Po Yen MD; Robert M. Starke MD MSc; Zhiyuan Xu MD; Jason P. Sheehan MD PhD FACS

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Ruptured intracranial arteriovenous malformations (AVM) are at a significantly greater risk for future hemorrhage than unruptured lesions thereby necessitating treatment in the majority of cases. We describe the radiosurgical outcomes for a large cohort of ruptured AVMs.

    Methods: From an institutional AVM radiosurgery database, we identified all patients with a history of AVM rupture. Those with less than 2 years radiologic follow-up were excluded except those with obliteration resulting in 565 ruptured AVM patients for analysis with a median radiologic follow-up of 57 months. The patients’ median age was 29 years, and 21% underwent pre-radiosurgery embolization. The median volume and prescription dose were 2.1 cc and 22 Gy, respectively. The Spetzler-Martin grade was III or higher in 56% of patients, the median radiosurgery-based AVM score was 1.08, and the Virginia Radiosurgery AVM Scale (RAS) was 3 to 4 points in 44%.

    Results: The cumulative obliteration rate was 76%, and the actuarial obliteration rates were 41% and 64% at 3 and 5 years, respectively. Multivariate analysis identified no pre-radiosurgery embolization (P<0.001), increased prescription dose (P=0.001), single draining vein (P=0.046), no post-radiosurgery hemorrhage (P=0.007), and lower Virginia RAS (P=0.020) as independent predictors of obliteration. The annual risk of latency period hemorrhage was 2.0% with a 1.6% rate of hemorrhage-related morbidity and mortality. Decreased prescription dose (P<0.001) and multiple draining veins (P=0.003) were independent predictors of post-radiosurgery hemorrhage based on multivariate analysis. The rates of symptomatic and permanent radiation-induced changes (RIC) were 8% and 2.7%, respectively. From multivariate analysis, single draining vein (P<0.001) and higher Virginia RAS (P=0.005) were independent predictors of RIC following radiosurgery.

    Conclusions: Radiosurgery effectively treats ruptured AVMs with an acceptably low risk to benefit ratio. For ruptured AVMs, favorable outcomes are more likely when pre-radiosurgical embolization is avoided and a higher prescription dose can be delivered.

    Patient Care: AVM rupture is the most devastating and feared and complication associated with this cerebrovascular pathology. Our retrospective analysis demonstrates that Gamma Knife radiosurgery affords a favorable risk to benefit profile for ruptured AVMs and identifies independent predictors of successful outcomes and complications.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) Describe the outcomes of Gamma Knife radiosurgery as a treatment approach for ruptured intracranial arteriovenous malformations, 2) Discuss, in small groups the patient, arteriovenous malformation and treatment characteristics which predict obliteration and radiation-induced changes following radiosurgery, and 3) Identify an effective treatment for ruptured arteriovenous malformations.

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