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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Embolization with Gamma Knife Radiosurgery of Giant Intracranial Arteriovenous Malformations
Dong Hyun Chun1, Moo Seong Kim, Sung Tae Kim
1Inje University, School of Medicine, Busan Paik Hospital, Department of Neurosurgery, Busan, Korea.
Insights
Giant arteriovenous malformations treated with embolization and Gamma Knife radiosurgery showed successful obliteration. Combining these treatments, especially with embolization first, improves outcomes for these difficult-to-treat vascular malformations.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Vascular Surgery
Background:
- Giant arteriovenous malformations (>6 cm or >33 cc) present significant treatment challenges.
- These malformations are associated with higher morbidity and mortality rates.
- Previous treatment outcomes for giant AVMs have been suboptimal.
Purpose of the Study:
- To evaluate the angiographic and clinical outcomes of treating giant arteriovenous malformations.
- To assess the efficacy of combined embolization and Gamma Knife radiosurgery.
- To determine the role of repeated Gamma Knife radiosurgery for residual AVM nidus.
Main Methods:
- Retrospective review of 11 patients with giant arteriovenous malformations treated between 1994 and 2012.
- Patients underwent embolization followed by Gamma Knife radiosurgery (GKRS).
- Mean radiation dose to the nidus margin was 14.2 Gy; mean AVM volume was 41 cc.
Main Results:
- Complete nidus obliteration was achieved in 36% of patients.
- Subtotal obliteration (>70% size reduction) was observed in 36% of patients.
- One patient experienced a small hemorrhage post-embolization.
Conclusions:
- Combined embolization and Gamma Knife radiosurgery is an effective treatment for giant arteriovenous malformations.
- Pre-radiosurgery embolization to reduce nidus size enhances treatment success.
- Repeated Gamma Knife radiosurgery is a viable option for residual nidus.
Aim:
Giant arteriovenous malformations (i.e., those greater than 6 cm maximum diameter or volume > 33 cc) are difficult to treat and often carry higher treatment morbidity and mortality rates. In our study, we reviewed the angiographic results and clinical outcomes for 11 patients with giant arteriovenous malformations who were treated between 1994 and 2012.
Material And Methods:
The patients selected included 9 males (82%) and 2 females (18%). Their presenting symptoms were hemorrhage (n=2; 18%), seizure (n=7; 64%), and headache (n=2; 12%). Nine patients were Spetzler-Martin Grade III, 2 were Spetzler-Martin Grade IV. The mean arteriovenous malformation volume was 41 cc (33-52 cc). The mean age of the patients was 45.1 years (24-57 years) and the mean radiation dose delivered to the margin of the nidus was 14.2 Gy.
Results:
Ten patients received pre-Gamma Knife radiosurgery embolization and Gamma Knife radiosurgery, 1 patient received pre-Gamma Knife radiosurgery embolization and Gamma Knife radiosurgery twice and the interval between Gamma Knife radiosurgeries was 3 months. The complete obliteration rate following Gamma Knife radiosurgery was 36%, subtotal obliteration ( > 70% decreased size of nidus) was 36%, and partial obliteration was 28%. One patient experienced a small hemorrhage after embolization.
Conclusion:
Combined embolization and Gamma Knife radiosurgery showed successful obliteration of the arteriovenous malformation nidus. The use of embolization to initially reduce nidus size followed by Gamma Knife radiosurgery improves the treatment results. Repeated Gamma Knife radiosurgery should be a treatment option when there is a small nidus remnant.
