J Korean Neurosurg Soc.  2020 Jul;63(4):415-426. 10.3340/jkns.2020.0008.

Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM

• Byun J
• Kwon DH
• Lee DH
• Park W
• Park JC
• Ahn JS

• KMID: 2504635
• DOI: http://doi.org/10.3340/jkns.2020.0008

Abstract

Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.

Keyword

Arteriovenous malformations; Radiosurgery; Complication

Figure

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  Fig. 1. Literature research for radiosurgery for large AVM. AVM : arteriovenous malformation.

Reference

References

1. Abla AA, Rutledge WC, Seymour ZA, Guo D, Kim H, Gupta N, et al. A treatment paradigm for high-grade brain arteriovenous malformations: volume-staged radiosurgical downgrading followed by microsurgical resection. J Neurosurg. 122:419–432. 2014.

2. Andrade-Souza YM, Ramani M, Beachey DJ, Scora D, Tsao MN, terBrugge K, et al. Liquid embolisation material reduces the delivered radiation dose: a physical experiment. Acta Neurochir (Wien). 150:161–164. discussion 164. 2008.

3. Aoyama H, Shiratoa H, Nishioka T, Kageia K, Onimarua R, Suzukic K, et al. Treatment outcome of single or hypofractionated single-isocentric stereotactic irradiation (STI) using a linear accelerator for intracranial arteriovenous malformation. Radiother Oncol. 59:323–328. 2001.

4. Awad AJ, Walcott BP, Stapleton CJ, Ding D, Leed CC, Loeffler JS. Repeat radiosurgery for cerebral arteriovenous malformations. J Clin Neurosci. 22:945–950. 2015.

5. Bir SC, Ambekar S, Maiti TK, Nanda A. Clinical outcome and complications of gamma knife radiosurgery for intracranial arteriovenous malformations. J Clin Neurosci. 22:1177–1122. 2015.

6. Boström JP, Bruckermann R, Pintea B, Boström A, Surber G, Hamm K. Treatment of cerebral arteriovenous malformations with radiosurgery or hypofractionated stereotactic radiotherapy in a consecutive pooled linear accelerator series. World Neurosurg. 94:328–338. 2016.

7. Chang TC, Shirato H, Aoyama H, Ushikoshi S, Kato N, Kuroda S, et al. Stereotactic irradiation for intracranial arteriovenous malformation using stereotactic radiosurgery or hypofractionated stereotactic radiotherapy. Int J Radiat Oncol Biol Phys. 60:861–870. 2004.

8. Chen JC, Mariscal L, Girvigian MR, Vanefsky MA, Glousman BN, Miller MJ, et al. Hypofractionated stereotactic radiosurgery for treatment of cerebral arteriovenous malformations: outcome analysis with use of the modified arteriovenous malformation scoring system. J Clin Neurosci. 29:155–161. 2016.

9. Chun DH, Kim MS, Kim ST, Paeng SH, Jeong HW, Lee WH. Embolization with gamma knife radiosurgery of giant intracranial arteriovenous malformations. Turk Neurosurg. 26:709–713. 2016.

10. Chytka T, Liscak R, Kozubiková P, Vymazal J. Radiosurgery for large arteriovenous malformations as a single-session or staged treatment. Stereotact Funct Neurosurg. 93:342–347. 2015.

11. Ding D, Yen CP, Starke RM, Xu Z, Sun X, Sheehan JP. Outcomes following single-session radiosurgery for high-grade intracranial arteriovenous malformations. Br J Neurosurg. 28:666–674. 2014.

12. Elhammady MS, Heros RC. Editorial: the ARUBA study: where do we go from here? J Neurosurg. 126:481–485. 2017.

13. Flickinger JC, Kondziolka D, Lunsford LD, Kassam A, Phuong LK, Liscak R, et al. Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Arteriovenous Malformation Radiosurgery Study Group. Int J Radiat Oncol Biol Phys. 46:1143–1148. 2000.

14. Flickinger JC, Kondziolka D, Lunsford LD, Pollock BE, Yamamoto M, Gorman DA, et al. A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys. 44:67–74. 1999.

15. Flickinger JC, Kondziolka D, Maitza AH, Lunsford LD. An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol. 63:347–354. 2002.

16. Flickinger JC, Kondziolka D, Pollock BE, Maitz AH, Lunsford LD. Complications from arteriovenous malformation radiosurgery: multivariate analysis and risk mudeling. Int J Radiat Oncol Biol Phys. 38:485–490. 1997.

17. Flickinger JC, Pollock BE, Kondziolka D, Lunsford LD. A dose-response analysis of arteriovenous malformation obliteration after radiosurgery. Int J Radiat Oncol Biol Phys. 36:873–879. 1996.

18. Foote KD, Friedman WA, Ellis TL, Bova FJ, Buatti JM, Meeks SL. Salvage retreatment after failure of radiosurgery in patients with arteriovenous malformations. J Neurosurg. 98:337–341. 2003.

19. Franzin A, Panni P, Spatola G, Del Vecchio A, Gallotti AL, Gigliotti CR, et al. Results of volume-staged fractionated gamma knife radiosurgery for large complex arteriovenous malformations: obliteration rates and clinical outcomes of an evolving treatment paradigm. J Neurosurg. 125(Suppl 1):104–113. 2016.

20. Friedman WA, Bova FJ, Bollampally S, Bradshaw P. Analysis of factors predictive of success or complications in arteriovenous malformation radiosurgery. Neurosurgery. 52:296–308. discussion 307-308. 2003.

21. Gobin YP, Laurent A, Merienne L, Schlienger M, Aymard A, Houdart E, et al. Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg. 85:19–28. 1996.

22. Gross BA, Du R. Natural history of cerebral arteriovenous malformations:a meta-analysis. J Neurosurg. 118:437–443. 2013.

23. Hanakita S, Shin M, Koga T, Igaki H, Saito N. Outcomes of volume-staged radiosurgery for cerebral arteriovenous malformations larger than 20 cm³ with more than 3 years of follow-up. World Neurosurg. 87:242–249. 2016.

24. Haw CS, terBrugge K, Willinsky R, Tomlinson G. Complications of embolization of arteriovenous malformations of the brain. J Neurosurg. 104:226–232. 2006.

25. Hodgson TJ, Kemeny AA, Gholkar A, Deasy N. Embolization of residual fistula following stereotactic radiosurgery in cerebral arteriovenous malformations. AJNR Am J Neuroradiol. 30:109–110. 2009.

26. Ilyas A, Ding D, Robert Hixson H, Xu Z, Starke RM, Sheehan JP. Volume-staged stereotactic radiosurgery for large intracranial arteriovenous malformations. J Clin Neurosci. 43:202–207. 2017.

27. Inoue HK. Long-term results of gamma knife surgery for arteriovenous malformations: 10- to 15-year follow up in patients treated with lower doses. J Neurosurg. 105 Suppl:64–68. 2006.

28. Izawa M, Hayashi M, Chernov M, Nakaya K, Ochiai T, Norikomurata , et al. Long-term complications after gamma knife surgery for arteriovenous malformations. J Neurosurg. 102 Suppl:34–37. 2005.

29. Kano H, Flickinger JC, Tonetti D, Hsu A, Yang HC, Flannery TJ, et al. Estimating the risks of adverse radiation effects after gamma knife radiosurgery for arteriovenous malformations. Stroke. 48:84–90. 2017.

30. Kano H, Kondziolka D, Flickinger JC, Park KJ, Iyer A, Yang HC, et al. Stereotactic radiosurgery after embolization for arteriovenous malformations. Prog Neurol Surg. 27:89–96. 2013.

31. Kano H, Kondziolka D, Flickinger JC, Park KJ, Iyer A, Yang HC, et al. Stereotactic radiosurgery for arteriovenous malformations after embolization: a case-control study. J Neurosurg. 117:265–275. 2012.

32. Karlsson B, Lax I, Soderman M. Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys. 49:1045–1051. 2001.

33. Karlsson B, Lindqvist M, Blomgren H, Wan-Yeo G, Söderman M, Lax I, et al. Long-term results after fractionated radiation therapy for large brain arteriovenous malformations. Neurosurgery. 57:42–49. discussion 42-49. 2005.

34. Kim JW, Chung HT, Han MH, Kim DG, Paek SH. Brain edema after repeat gamma knife radiosurgery for a large arteriovenous malformation: a case report. Exp Neurobiol. 25:191–196. 2016.

35. Maesawa S, Flickinger JC, Kondziolka D, Lunsford LD. Repeated radiosurgery for incompletely obliterated arteriovenous malformations. J Neurosurg. 92:961–970. 2000.

36. Marks MP, Marcellus ML, Santarelli J, Dodd RL, Do HM, Chang SD, et al. Embolization followed by radiosurgery for the treatment of brain arteriovenous malformations (AVMs). World Neurosurg. 99:471–476. 2017.

37. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 383:614–621. 2014.

38. Moosa S, Chen CJ, Ding D, Lee CC, Chivukula S, Starke RM, et al. Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations. Neurosurg Focus. 3:E18. 2014.

39. Murray AL, Dally M, Jeffreys A, Hwang P, Anderson JF. Neuropsychological outcomes of stereotactic radiotherapy for cerebral arteriovenous malformations. J Clin Neurosci. 21:601–606. 2014.

40. Nagy G, Grainger A, Hodgson TJ, Rowe JG, Coley SC, Kemeny AA, et al. Staged-volume radiosurgery of large arteriovenous malformations improves outcome by reducing the rate of adverse radiation effects. Neurosurgery. 80:180–192. 2017.

41. Park HR, Lee JM, Kim JW, Han JH, Chung HT, Han MH, et al. Time-staged gamma knife stereotactic radiosurgery for large cerebral arteriovenous malformations: a preliminary report. PLoS One. 11:e0165783. 2016.

42. Park JC, Ahn JS, Kwon DH, Kwun BD. growing organized hematomas following gamma knife radiosurgery for cerebral arteriovenous malformation : five cases of surgical excision. J Korean Neurosurg Soc. 58:83–88. 2015.

43. Pollock BE, Kline RW, Stafford SL, Foote RL, Schomberg PJ. The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys. 48:817–824. 2000.

44. Pollock BE, Kondziolka D, Lunsford LD, Bissonette D, Flickinger JC. Repeat stereotactic radiosurgery of arteriovenous malformations: factors associated with incomplete obliteration. Neurosurgery. 38:318–324. 1996.

45. Pollock BE, Link MJ, Stafford SL, Lanzino G, Garces YI, Foote RL. Volume-staged stereotactic radiosurgery for intracranial arteriovenous malformations: outcomes based on an 18-year experience. Neurosurgery. 80:543–550. 2017.

46. Potts MB, Zumofen DW, Raz E, Nelson PK, Riina HA. Curing arteriovenous malformations using embolization. Neurosurg Focus. 37:E19. 2014.

47. Rao VRK, Mandalam KR, Gupta AK, Kumar S, Joseph S. Dissolution of isobutyl 2-cyanoacrylate on longterm follow-up. AJNR Am J Neuroradiol. 10:135–141. 1989.

48. Reig AS, Rajaram R, Simon S, Mericle RA. Complete angiographic obliteration of intracranial AVMs with endovascular embolization: incomplete embolic nidal opacification is associated with AVM recurrence. J Neurointerv Surg. 2:202–207. 2010.

49. Seymour ZA, Sneed PK, Gupta N, Lawton MT, Molinaro AM, Young W, et al. Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm. J Neurosurg. 124:163–174. 2016.

50. Shtraus N, Schifter D, Corn BW, Maimon S, Alani S, Frolov V, et al. Radiosurgical treatment planning of AVM following embolization with Onyx: possible dosage error in treatment planning can be averted. J Neurooncol. 98:271–276. 2010.

51. Sirin S, Kondziolka D, Niranjan A, Flickinger JC, Maitz AH, Lunsford LD. Prospective staged volume radiosurgery for large arteriovenous malformations: indications and outcomes in otherwise untreatable patients. Neurosurgery. 58:17–27. discussion 17-27. 2006.

52. Spetzler RF, Ponce FA. A 3-tier classification of cerebral arteriovenous malformations. Clinical article. J Neurosurg. 114:842–849. 2011.

53. Stahl JM, Chi YY, Friedman WA. Repeat radiosurgery for intracranial arteriovenous malformations. Neurosurgery. 70:150–154. discussion 154. 2012.

54. Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, et al. Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology. 66:1350–1355. 2006.

55. van Beijnum J, van der Worp HB, Buis DR, Al-Shahi Salman R, Kappelle LJ, Rinkel GJ, et al. Treatment of brain arteriovenous malformations: a systematic review and meta-analysis. JAMA. 306:2011–2019. 2011.

56. Veznedaroglu E, Andrews DW, Benitez RP, Downes MB, Werner-Wasik M, Rosenstock J, et al. Fractionated stereotactic radiotherapy for the treatment of large arteriovenous malformations with or without previous partial embolization. Neurosurgery. 55:519–531. discussion 530-531. 2004.

57. Wong J, Slomovic A, Ibrahim G, Radovanovic I, Tymianski M. Microsurgery for ARUBA Trial (a randomized trial of unruptured brain arteriovenous malformation)-eligible unruptured brain arteriovenous malformations. Stroke. 48:136–144. 2017.

58. Xiao F, Gorgulho AA, Lin CS, Chen CH, Agazaryan N, Viñuela F, et al. Treatment of giant cerebral arteriovenous malformation: hypofractionated stereotactic radiation as the first stage. Neurosurgery. 67:1253–1259. discussion 1259. 2010.

59. Yun JH, Kwon DH, Lee EJ, Lee DH, Ahn JS, Kwun BD. New nidus formation adjacent to the target site of an arteriovenous malformation treated by gamma knife surgery. J Neurosurg. 117 Suppl:120–125. 2012.

60. Zhang Q, Jing L, Liu J, Wang K, Zhang Y, Paliwal N, et al. Predisposing factors for recanalization of cerebral aneurysms after endovascular embolization: a multivariate study. J Neurointerv Surg. 10:252–257. 2018.

61. Zhong J, Press RH, Olson JJ, Oyesiku NM, Shu HG, Eaton BR. The use of hypofractionated radiosurgery for the treatment of intracranial lesions unsuitable for single-fraction radiosurgery. Neurosurgery. 83:850–857. 2018.