J Korean Neurosurg Soc.  2024 Jul;67(4):431-441. 10.3340/jkns.2023.0177.

Feasibility of Gamma Knife Radiosurgery for Brain Arteriovenous Malformations According to Nidus Type

• Koo JH
• Hwang EH
• Song JH
• Lim YC

• KMID: 2556740
• DOI: http://doi.org/10.3340/jkns.2023.0177

Abstract

Objective
: Gamma Knife radiosurgery (GKRS) is an effective and noninvasive treatment for high-risk arteriovenous malformations (AVMs). Since differences in GKRS outcomes by nidus type are unknown, this study evaluated GKRS feasibility and safety in patients with brain AVMs.
Methods
: This single-center retrospective study included patients with AVM who underwent GKRS between 2008 and 2021. Patients were divided into compact- and diffuse-type groups according to nidus characteristics. We excluded patients who performed GKRS and did not follow-up evaluation with magnetic resonance imaging or digital subtraction angiography within 36 months from the study. We used univariate and multivariate analyses to characterize associations of nidus type with obliteration rate and GKRS-related complications.
Results
: We enrolled 154 patients (mean age, 32.14±17.17 years; mean post-GKRS follow-up, 52.10±33.67 months) of whom 131 (85.1%) had compact- and 23 (14.9%) diffuse-type nidus AVMs. Of all AVMs, 89 (57.8%) were unruptured, and 65 (42.2%) had ruptured. The mean Spetzler-Martin AVM grades were 2.03±0.95 and 3.39±1.23 for the compact- and diffuse-type groups, respectively (p<0.001). During the follow-up period, AVM-related hemorrhages occurred in four individuals (2.6%), three of whom had compact nidi. Substantial radiation-induced changes and cyst formation were observed in 21 (13.6%) and one patient (0.6%), respectively. The AVM complete obliteration rate was 46.1% across both groups. Post-GKRS complication and complete obliteration rates were not significantly different between nidus types. For diffuse-type nidus AVMs, larger AVM size and volume (p<0.001), lower radiation dose (p<0.001), eloquent area location (p=0.015), and higher Spetzler-Martin grade (p<0.001) were observed.
Conclusion
: GKRS is a safe and feasible treatment for brain AVMs characterized by both diffuse- and compact-type nidi.

Keyword

Arteriovenous malformations; Vascular malformations; Radiosurgery; Complications; Gamma rays

Figure

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  Fig. 1. Differences between two types of arteriovenous malformation (AVM) nidus. A : Compact-type AVM with a well-demarcated nidus. B : Diffuse-type AVM with an unclear nidus surrounding normal brain tissue.

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  Fig. 2. Kaplan-Meier curve showing complete obliteration of arteriovenous malformations (AVMs) after gamma-knife radiosurgery in compact-type and diffuse-type nidi.

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  Fig. 3. Post-Gamma Knife radiosurgery complications. A : Hemorrhage. Non-enhanced computed tomography (CT) scan shows acute intracranial hemorrhage in the left temporal lobe (red arrow). B : Radiation induced change. In the T1 magnetic resonance imaging image, radiation-induced edematous change is observed around the arteriovenous malformation (AVM) nidus in the left precentral gyrus (red arrow). C : Cystic formation. Hypodense cystic formation are visible around the AVM in the enhanced CT scan (red arrow).

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  Fig. 4. A : T2-weighted magnetic resonance imaging shows an compact-type arteriovenous malformation (AVM). B : Digital subtraction angiography confirmed 2.4×1.8 cm sized AVM in right occipital lobe cortical region, with feeding vessels from terminal branch of right anterior cerebral artery, middle cerebral artery, posterior cerebral artery and draining via posterior one third of superior sagittal sinus. C : Gamma Knife radiosurgery (GKRS) target location is shown (1.8 mL, 20 Gy to 50% of isodense line). D : The follow-up angiography revealed (41 months after GKRS) complete obliteration of the AVM.

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  Fig. 5. A : T1-weighted enhanced magnetic resonance imaging shows an diffuse-type enhanced arteriovenous malformation (AVM). B : Digital subtraction angiography confirmed 4.2×3.8 cm sized AVM in left posterior parietal lobe cortical region, with feeding vessels from left anterior cerebral artery, middle cerebral artery, posterior cerebral artery and transdural collaterals from middle meningeal artery posterior division draining via cortical vein to superior sagittal sinus and vein of Labbe to sigmoid sinus. C : Gamma Knife Radiosurgery (GKRS) target location is shown (14.1 mL, 14 Gy to 50% of isodense line). D : The follow-up angiography revealed (34 months after GKRS) complete obliteration of AVM.

Reference

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