title: Stereotactic radiosurgery for sylvian fissure arteriovenous malformations with emphasis on hemorrhage risks and seizure outcomes.
abstract: OBJECTIVE
  Sylvian fissure arteriovenous malformations (AVMs) present substantial management challenges because of the critical adjacent blood vessels and functional brain. The authors investigated the outcomes, especially hemorrhage and seizure activity, after stereotactic radiosurgery (SRS) of AVMs within or adjacent to the sylvian fissure.
  
  
  METHODS
  This retrospective single-institution analysis examined the authors' experiences with Gamma Knife surgery for AVMs of the sylvian fissure in cases treated from 1987 through 2009. During this time, 87 patients underwent SRS for AVMs in the region of the sylvian fissure. Before undergoing SRS, 40 (46%) of these patients had experienced hemorrhage and 36 (41%) had had seizures. The median target volume of the AVM was 3.85 cm(3) (range 0.1-17.7 cm(3)), and the median marginal dose of radiation was 20 Gy (range 13-25 Gy).
  
  
  RESULTS
  Over a median follow-up period of 64 months (range 3-275 months), AVM obliteration was confirmed by MRI or angiography for 43 patients. The actuarial rates of confirmation of total obliteration were 35% at 3 years, 60% at 4 and 5 years, and 76% at 10 years. Of the 36 patients who had experienced seizures before SRS, 19 (53%) achieved outcomes of Engel class I after treatment. The rate of seizure improvement was 29% at 3 years, 36% at 5 years, 50% at 10 years, and 60% at 15 years. No seizures developed after SRS in patients who had been seizure free before treatment. The actuarial rate of AVM hemorrhage after SRS was 5% at 1, 5, and 10 years. This rate equated to an annual hemorrhage rate during the latency interval of 1%; no hemorrhages occurred after confirmed obliteration. No permanent neurological deficits developed as an adverse effect of radiation; however, delayed cyst formation occurred in 3 patients.
  
  
  CONCLUSIONS
  Stereotactic radiosurgery was an effective treatment for AVMs within the region of the sylvian fissure, particularly for smaller-volume AVMs. After SRS, a low rate of hemorrhage and improved seizure control were also evident.
authors.affiliation: Departments of Neurological Surgery and.
authors.forename: Greg
authors.initials: G
authors.lastname: Bowden
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Kano
authors.forename: Daniel
authors.initials: D
authors.lastname: Tonetti
authors.forename: Ajay
authors.initials: A
authors.lastname: Niranjan
authors.forename: John
authors.initials: J
authors.lastname: Flickinger
authors.forename: Yoshio
authors.initials: Y
authors.lastname: Arai
authors.forename: L Dade
authors.initials: LD
authors.lastname: Lunsford
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000453:epidemiology*; D002550:Cerebral Veins / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D002538:Intracranial Arteriovenous Malformations / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery; D012189:Retrospective Studies; D012307:Risk Factors; D012640:Seizures / Q000453:epidemiology*; D016896:Treatment Outcome; D055815:Young Adult
keywords: AVM = arteriovenous malformation; Gamma Knife; SRS = stereotactic radiosurgery; arteriovenous malformation; epilepsy; seizure; stereotactic radiosurgery; sylvian fissure; vascular disorders