Massengale Justin L, Levy Richard P, Marcellus Mary, Moes Gregory, Marks Michael P, Steinberg Gary K
Department of Neurosurgery Stanford University, Stanford, California 94305, USA.
Neurosurgery. 2006 Sep;59(3):553-60; discussion 553-60. doi: 10.1227/01.NEU.0000227476.95859.F1.
Although radiation injury after stereotactic radiosurgery (SRS), including radiation necrosis (RN), is often treated with surgical resection, detailed outcome data are lacking after resection of symptomatic radiation-injured regions with imaging characteristics suspicious for RN after SRS for arteriovenous malformations (AVM). We present outcomes in seven such patients.
We conducted a retrospective chart review of seven patients with AVMs of Spetzler-Martin Grades II (n = 1), III (n = 2), and IV (n = 4) who underwent helium ion, proton beam, or gamma knife SRS and required resection of RN-suspicious tissue 1 to 24 months after post-SRS symptom onset. Postoperative outcomes included Karnofsky Performance Scale (KPS) score and time to symptomatic improvement.
Symptomatic improvement required at least 9 months in the three patients with large regions suspicious for RN (>or=4 cm), whereas of four patients with smaller regions (<4 cm), three showed improvement within 2 months (P < 0.05). The remaining patient, who showed no benefit, underwent resection 2 years after the onset of RN symptoms (compared with <or= 8 mo for the other six patients). Surgery improved KPS scores in four patients with a preoperative KPS score of 50 or lower, but not in three patients with preoperative KPS scores greater than 70 (P < 0.05). Outcomes were not consistently associated with AVM size or location, SRS treatment volume or dose, associated aneurysm, or residual AVM.
After SRS for AVMs, resection of symptomatic RN-suspicious tissue areas is beneficial in reversing neurological deficits and improving KPS scores in selected patients. Times to improvement were longer when larger areas were resected. Delaying such surgery after symptom onset may negatively affect improvement.
尽管立体定向放射外科治疗（SRS）后的放射性损伤，包括放射性坏死（RN），通常采用手术切除治疗，但对于因动静脉畸形（AVM）接受SRS治疗后出现具有RN可疑影像学特征的有症状放射性损伤区域进行切除后，详细的结果数据尚缺乏。我们报告7例此类患者的治疗结果。
我们对7例Spetzler-Martin分级为II级（n = 1）、III级（n = 2）和IV级（n = 4）的AVM患者进行了回顾性病历审查，这些患者接受了氦离子、质子束或伽玛刀SRS治疗，且在SRS后症状出现1至24个月需要切除可疑RN的组织。术后结果包括卡氏功能状态评分（KPS）和症状改善时间。
对于3例可疑RN区域较大（≥4 cm）的患者，症状改善至少需要9个月，而对于4例可疑RN区域较小（<4 cm）的患者，3例在2个月内出现改善（P < 0.05）。其余1例无改善的患者在RN症状出现2年后接受了切除手术（其他6例患者为≤8个月）。手术使4例术前KPS评分为50或更低的患者的KPS评分得到改善，但3例术前KPS评分大于70的患者未得到改善（P < 0.05）。结果与AVM大小或位置、SRS治疗体积或剂量、相关动脉瘤或残留AVM无一致关联。
对于AVM患者接受SRS治疗后，切除有症状的可疑RN组织区域有利于在部分患者中逆转神经功能缺损并提高KPS评分。切除区域较大时改善时间较长。症状出现后延迟此类手术可能对改善产生负面影响。
