Radiosurgery for arteriovenous malformations of the basal ganglia, thalamus, and brainstem.
OBJECTIVE
Although stereotactic radiosurgery is frequently performed for arteriovenous malformations (AVMs) in deep locations, outcomes after radiosurgery for these patients have not been well studied. The goal of this paper was to study these outcomes.


METHODS
Between 1990 and 2000, 56 patients underwent radiosurgery for AVMs located in the basal ganglia (10 patients), thalamus (30 patients), or brainstem (16 patients). The median age of these patients was 34.2 years. Thirty-five patients (62%) had experienced previous bleeding. The AVMs were classified Grade IIIB in 62% of patients and Grade IV in 38% according to the modified Spetzler-Martin Scale; the median radiosurgery-based AVM score was 1.83. The median volume of the lesion was 3.8 cm3 and the median radiation dose delivered to its margin was 18 Gy. The median duration of follow-up review after radiosurgery was 45 months (range 3-121 months). In seven patients (12%) hemorrhage occurred at a median of 12 months after radiosurgery; five patients (9%) died and two recovered without any deficit. Permanent radiation-related complications occurred in six (12%) of 51 patients (excluding the five patients who died of hemorrhage) after one procedure and in three (18%) of 17 patients after repeated radiosurgery. Obliteration of the AVM was noted in 24 patients (43%; obliteration was confirmed by angiography in 18 patients and by magnetic resonance [MR] imaging in six patients) after a single procedure and in 32 patients (57%; confirmed by angiography in 25 patients and by MR imaging in seven patients) after one or more procedures. Excellent outcomes (obliteration of the lesion without any new deficit) were obtained in 39% of patients after one radiosurgical procedure and in 48% after one or more procedures. Twelve (67%) of 18 patients with AVM scores lower than 1.5 had excellent outcomes compared with 15 (39%) of 38 patients with AVM scores greater than 1.5 (p = 0.053).


CONCLUSIONS
Less than half of the patients with deeply located AVMs were cured of the future risk of hemorrhage without new neurological deficits. This experience emphasizes the difficulty in treating patients with deeply located AVMs; the majority of whom are also poor candidates for resection or embolization.
Pollock
Bruce E
BE
Department of Neurologic Surgery, Division of Radiation Oncology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA. pollock.bruce@mayo.edu
Gorman
Deborah A
DA
Brown
Paul D
PD
D000328:Adult; D001479:Basal Ganglia / Q000601:surgery; D001933:Brain Stem / Q000601:surgery; D002543:Cerebral Hemorrhage / Q000209:etiology*; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000532:radiotherapy / Q000601:surgery*; D008297:Male; D011832:Radiation Injuries / Q000209:etiology*; D016634:Radiosurgery / Q000009:adverse effects*; D013788:Thalamus / Q000601:surgery; D016896:Treatment Outcome