Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations

The management of Spetzler-Martin Grade-IV and -V arteriovenous malformations (AVMs) is controversial due to their uncertain natural history, the high rate of morbidity and mortality associated with microsurgical resection, and the relatively low rate of successful obliteration from less invasive approaches such as radiosurgery and embolization. We present our radiosurgical results for high-grade AVMs.

We identified all patients with Spetzler-Martin Grade-IV and -V AVMs treated with single-session radiosurgery at the University of Virginia between 1989 and 2009. Patients with less than 2 years of follow-up without obliteration were excluded. This yielded 110 patients with a median age 27.6 years. The median AVM volume was 5.7 cc and prescription dose was 19 Gy. The median radiographic and clinical follow-up intervals were 88 and 97 months, respectively.

Complete AVM obliteration was identified on MRI only in 11 patients (10%) and confirmed by DSA in 38 patients (34%) for a cumulative obliteration rate of 44%. The actuarial rates of obliteration at 3 and 5 years were 10% and 23%, respectively. The mean and median times to obliteration were 60 months and 43 months, respectively. Significant independent predictors of obliteration were no pre-radiosurgery embolization (P = 0.008), superficial location (P = 0.001), and higher prescription dose (P = 0.028). The annual rate of post-radiosurgery hemorrhage was 3.0%, and symptomatic RIC was observed in 12% of patients. Unruptured AVMs were more likely to have RIC (P = 0.005). The rates of temporary and permanent post-radiosurgery clinical deterioration were 9% and 10%, respectively.

Single-session radiosurgery is an acceptable treatment option for select patients harboring high-grade AVMs for which microsurgery or conservative management are associated with an unacceptably high risk of adverse outcomes.