The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations.
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.
Maruyama
Keisuke
K
Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan. kskmaru-tky@umin.ac.jp
Kawahara
Nobutaka
N
Shin
Masahiro
M
Tago
Masao
M
Kishimoto
Junji
J
Kurita
Hiroki
H
Kawamoto
Shunsuke
S
Morita
Akio
A
Kirino
Takaaki
T
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