Andrade-Souza Yuri M, Zadeh Gelareh, Scora Daryl, Tsao May N, Schwartz Michael L
Division of Neurosurgery, Sunnybrook and Women's College, Health Science Centre,University of Toronto, Toronto, Ontario, Canada.
Neurosurgery. 2005;56(1):56-63; discussion 63-4. doi: 10.1227/01.neu.0000145797.35968.ed.
Radiosurgery is accepted as the first option for treating deep arteriovenous malformations (AVMs), although the clinical outcome in this subgroup of brain AVMs is not well studied. The objective of this study is to review our experience with radiosurgical treatment for these AVMs.
Between October 1989 and December 2000, 45 patients with deep AVMs (including basal ganglia, internal capsule, and thalamus) underwent stereotactic radiosurgery. Three patients were lost to follow-up and therefore were excluded from this study. Patient characteristics and outcomes were collected and analyzed. The obliteration prediction index and the radiosurgery-based AVM score were calculated and tested.
Forty-two patients were followed up for a median of 39 months (range, 25-90 mo; mean, 45.8 mo). The median maximum AVM diameter during the radiosurgery was 1.8 cm (range, 0.9-4.0 cm; mean, 2.07 cm), and the median AVM volume was 2.8 cm(3) (range, 0.2-18.3 cm(3); mean, 4.74 cm(3)). The mean marginal dose was 16.2 Gy (median, 15 Gy), and the median maximum dose was 22.4 Gy (range, 16.6-30 Gy). The AVM cure rate after the first radiosurgical treatment, using angiography- and magnetic resonance imaging-confirmed obliteration, was 61.9%. The predicted obliteration using the obliteration prediction index was 60%. Eight patients developed radiation-induced complications (19%). The deficit was transient in three patients (7.1%) and permanent in five patients (11.9%). The risk of postradiosurgical hemorrhage in this cohort was 9.5% for the first year, 4.7% for the second year, and 0% thereafter. Excellent outcome (obliteration plus no new deficit) was achieved in 70% of the patients in the group with radiosurgery-based AVM score less than 1.5 compared with 40.9% in the group with radiosurgery-based AVM score greater than 1.5% (P = 0.059).
Radiosurgery for deep AVMs has a satisfactory obliteration rate and acceptable morbidity, considering the risk of hemorrhage without treatment and the risk of morbidity associated with other treatment modalities.
放射外科手术被公认为治疗深部动静脉畸形（AVM）的首选方法，尽管对于这一亚组脑AVM的临床疗效尚未得到充分研究。本研究的目的是回顾我们对这些AVM进行放射外科治疗的经验。
1989年10月至2000年12月期间，45例深部AVM（包括基底节、内囊和丘脑）患者接受了立体定向放射外科手术。3例患者失访，因此被排除在本研究之外。收集并分析患者的特征和结局。计算并测试闭塞预测指数和基于放射外科的AVM评分。
42例患者接受了中位39个月的随访（范围25 - 90个月；平均45.8个月）。放射外科手术期间AVM的最大直径中位数为1.8 cm（范围0.9 - 4.0 cm；平均2.07 cm），AVM体积中位数为2.8 cm³（范围0.2 - 18.3 cm³；平均4.74 cm³）。平均边缘剂量为16.2 Gy（中位数15 Gy），最大剂量中位数为22.4 Gy（范围16.6 - 30 Gy）。首次放射外科治疗后，经血管造影和磁共振成像证实闭塞的AVM治愈率为61.9%。使用闭塞预测指数预测的闭塞率为60%。8例患者出现放射性并发症（19%）。3例患者（7.1%）的神经功能缺损为短暂性，5例患者（11.9%）为永久性。该队列中放射外科手术后第一年出血风险为9.5%，第二年为4.7%，此后为0%。基于放射外科的AVM评分小于1.5的患者组中70%取得了良好结局（闭塞且无新的神经功能缺损），而基于放射外科的AVM评分大于1.5的患者组中这一比例为40.9%（P = 0.059）。
考虑到未经治疗时的出血风险以及与其他治疗方式相关的发病风险，深部AVM的放射外科手术具有令人满意的闭塞率和可接受的发病率。
