title: The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations.
abstract: BACKGROUND
  Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage is poorly understood.
  
  
  METHODS
  We performed a retrospective observational study of 500 patients with malformations who were treated with radiosurgery with use of a gamma knife. The rates of hemorrhage were assessed during three periods: before radiosurgery, between radiosurgery and the angiographic documentation of obliteration of the malformation (latency period), and after angiographic obliteration.
  
  
  RESULTS
  Forty-two hemorrhages were documented before radiosurgery (median follow-up, 0.4 year), 23 during the latency period (median follow-up, 2.0 years), and 6 after obliteration (median follow-up, 5.4 years). As compared with the period between diagnosis and radiosurgery, the risk of hemorrhage decreased by 54 percent during the latency period (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P<0.001). The risk was significantly reduced during the period after obliteration, as compared with the latency period (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). The reduction was greater among patients who presented with hemorrhage than among those without hemorrhage at presentation and similar in analyses that took into account the delay in confirming obliteration by means of angiography and analyses that excluded data obtained during the first year after diagnosis.
  
  
  CONCLUSIONS
  Radiosurgery significantly decreases the risk of hemorrhage in patients with cerebral arteriovenous malformations, even before there is angiographic evidence of obliteration. The risk of hemorrhage is further reduced, although not eliminated, after obliteration.
authors.affiliation: Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan. kskmaru-tky@umin.ac.jp
authors.forename: Keisuke
authors.initials: K
authors.lastname: Maruyama
authors.forename: Nobutaka
authors.initials: N
authors.lastname: Kawahara
authors.forename: Masahiro
authors.initials: M
authors.lastname: Shin
authors.forename: Masao
authors.initials: M
authors.lastname: Tago
authors.forename: Junji
authors.initials: J
authors.lastname: Kishimoto
authors.forename: Hiroki
authors.initials: H
authors.lastname: Kurita
authors.forename: Shunsuke
authors.initials: S
authors.lastname: Kawamoto
authors.forename: Akio
authors.initials: A
authors.lastname: Morita
authors.forename: Takaaki
authors.initials: T
authors.lastname: Kirino
mesh_terms: D000328:Adult; D002533:Cerebral Angiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000601:surgery*; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D016016:Proportional Hazards Models; D016634:Radiosurgery; D012189:Retrospective Studies; D012306:Risk