J Korean Med Sci.  2024 Jul;39(29):e217. 10.3346/jkms.2024.39.e217.

Long-Term Outcome of Time-Staged Gamma Knife Radiosurgery for Large Arteriovenous Malformations

• Myeong HS
• Jeong SS
• Kim JH
• Lee JM
• Park KH
• Park K
• Park HJ
• Park HR
• Yoon BW
• Hahn S
• Lee EJ
• Kim JW
• Chung HT
• Kim DG
• Paek SH

• KMID: 2558260
• DOI: http://doi.org/10.3346/jkms.2024.39.e217

Abstract

Background
Treatment for large (> 10 mL) arteriovenous malformations (AVMs) remains highly challenging. This study evaluated long-term effect of time-staged gamma knife radiosurgery (GKS) for large AVMs. Methods: For patients with large AVMs treated by time-staged GKS over 10 years, timestaged GKS was repeated every three years targeting the entire nidus if total obliteration was not achieved. Obliteration rate and post-GKS complications were assessed based on 10 mL volume interval of AVMs. Prognostic factors for these outcomes were evaluated using Cox regression analysis.
Results
Ninety-six patients were analyzed. For AVMs in the 10–20 mL subgroup, a dose ≥ 13.5Gy yielded higher obliteration rate in the first GKS. In the 20–30 mL subgroup, a second GKS significantly boosted obliteration. AVMs > 30 mL did not achieve any obliteration with the first GKS. Among 35 (36.4%) cases lost to follow-up, 7 (7.2%) were lost due to GKS complications. Kaplan-Meier analysis showed that each subgroup needed different time for achieving 50% favorable obliteration outcome rate: 3.5, 6.5, and 8.2 years for 10–20 mL, 20–30 mL, and > 30 mL subgroup, respectively. Total obliteration rate calculated by intention-to-treat method: 73%, 51.7%, 35.7%, respectively, 61.5% overall. Post-GKS hemorrhage and chronic encapsulated expanding hematoma (CEEH) occurred in 13.5% and 8.3% of cases, respectively. Two patients died. Dose and volume were significant prognostic factors for obliteration. Initial AVM volume was a significant prognostic factor of post-GKS hemorrhage and CEEH.
Conclusion
Time-staged GKS for large AVMs less than 30 mL has highly favorable long-term outcome and a tolerable complication rate.

Keyword

Time-Staged Gamma Knife Radiosurgery; Large Arteriovenous Malformation; Long-Term Outcome; Minimal Residual Shunt; Chronic Encapsulated Expanding Hematoma

Figure

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  Fig. 1 Spontaneous regression of minimal residual shunt. An AVM with a volume of 13 mL was located in the right parietal lobe. (A) Angiographic finding of AVM before 1st GKS; (B) Angiographic finding of AVM before 2nd GKS which showed reduced nidus volume; (C) A state of minimal residual shunt was confirmed at 3 years after the 2nd GKS. Minimal arteriovenous shunt flow was indicated; (D) Without additional GKS, spontaneous regression was confirmed by angiography one year after.GKS = gamma knife radiosurgery, AVM = arteriovenous malformation.

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  Fig. 2 CEEH. An AVM with a volume of 20.3 mL was located in the left parieto-occipital lobe. (A) Six years after the first GKS and 3 years after the second GKS. The AVM exhibited a minimal residual shunt state; (B) At the time of the third GKS, CEEH occurred with perilesional edema; (C, D) CEEH did not shrink and perilesional edema gradually worsened, resulting in drowsiness. Surgery was recommended but parents did not agree. The patient was transferred to another hospital by the request of parents. There was no record of this patient on the mortality registry of South Korea until 2023.GKS = gamma knife radiosurgery, CEEH = chronic encapsulated expanding hematoma, AVM = arteriovenous malformation.

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  Fig. 3 Dose-volume scatter plot & Subgroup-specific Kaplan-Meier curves depicting obliteration rates and complications. (A) Initial AVM volume and first GKS dose scatter plot with final obliteration outcomes. Blue circle indicates follow-up loss patients including not participating further treatment or not undergoing follow-up angiography of residual AVM patients. Yellow circle indicates minimal residual shunt, green circle indicates residual AVM and red circle indicates total obliteration; (B) Initial AVM volume and first GKS dose scatter plot with first GKS outcomes; (C) AVM volume at the second stage and second GKS dose scatter plot with second GKS outcomes whose follow-up angiography was available. (C) In 10–20 mL subgroup, significant difference of favorable obliteration outcome rate was shown based on 13.5 Gy cut-off (long rank test, P = 0.006); (D) Favorable obliteration outcome rate of each subgroup; (E) Post gamma knife radiosurgery (GKS) hemorrhage rate of each subgroup. Repeat hemorrhage event was also included in analysis; (F) Post-GKS CEEH rate of each subgroup.GKS = gamma knife radiosurgery, AVM = arteriovenous malformation, CEEH = chronic encapsulated expanding hematoma.

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