title: Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Retrospective Matched-Cohort Study.
abstract: BACKGROUND
  Incompletely obliterated cerebral arteriovenous malformations (AVMs) after initial treatment with stereotactic radiosurgery (SRS) can be treated with a repeat session of SRS. However, the relative efficacy of repeat vs initial SRS is not well specified.
  
  
  OBJECTIVE
  To retrospectively compare in matched cohorts the outcomes of repeat vs initial SRS for the treatment of matched cohorts with angioarchitecturally similar AVMs.
  
  
  METHODS
  We studied a data set of patients with AVM treated with radiosurgery during the period spanning 1989 to 2013. Patients with AVM who underwent repeat SRS with radiologic follow-up of ≥2 years or nidus obliteration were identified for the study and matched, in a 1:1 fashion that was blinded to outcome, to patients with previously untreated AVMs who underwent initial SRS. Statistical analyses were performed to compare the outcomes after repeat vs initial SRS.
  
  
  RESULTS
  The matching approach resulted in 84 patients for the repeat and the initial SRS cohort (mean margin doses, 20.7 and 20.9 Gy, respectively; P = .74). In the repeat SRS cohort, obliteration was achieved in 67%; the radiologic, symptomatic, and permanent radiation-induced change rates were 35%, 10%, and 4%, respectively; and the post-SRS hemorrhage rate was 3.1%/y. Compared with the initial SRS cohort, the repeat SRS cohort had significantly lower obliteration rates (P = .04) and higher post-SRS hemorrhage rates (P = .04). The radiation-induced change rates of the 2 cohorts were not significantly different.
  
  
  CONCLUSIONS
  Repeat SRS yields considerably poorer outcomes than initial SRS for angioarchitecturally comparable AVMs. Further studies in AVM radiobiology and vascular structure are necessary to elucidate this potentially differential response.
  
  
  BACKGROUND
  AVM, arteriovenous malformationRIC, radiation-induced changeRBAS, radiosurgery-based arteriovenous malformation scoreSRS, stereotactic radiosurgeryVRAS, virginia radiosurgery AVM scale.
authors.affiliation: Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.forename: Zhiyuan
authors.initials: Z
authors.lastname: Xu
authors.forename: Han-Hsun
authors.initials: HH
authors.lastname: Shih
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Chun-Po
authors.initials: CP
authors.lastname: Yen
authors.forename: Or
authors.initials: O
authors.lastname: Cohen-Inbar
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult