Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
J Neurosurg. 2013 May;118(5):958-66. doi: 10.3171/2013.2.JNS121239. Epub 2013 Mar 26.
The appropriate management of unruptured intracranial arteriovenous malformations (AVMs) remains controversial. In the present study, the authors evaluate the radiographic and clinical outcomes of radiosurgery for a large cohort of patients with unruptured AVMs.
From a prospective database of 1204 cases of AVMs involving patients treated with radiosurgery at their institution, the authors identified 444 patients without evidence of rupture prior to radiosurgery. The patients' mean age was 36.9 years, and 50% were male. The mean AVM nidus volume was 4.2 cm(3), 13.5% of the AVMs were in a deep location, and 44.4% were at least Spetzler-Martin Grade III. The median radiosurgical prescription dose was 20 Gy. Univariate and multivariate Cox regression analyses were used to determine risk factors associated with obliteration, postradiosurgery hemorrhage, radiation-induced changes, and postradiosurgery cyst formation. The mean duration of radiological and clinical follow-up was 76 months and 86 months, respectively.
The cumulative AVM obliteration rate was 62%, and the postradiosurgery annual hemorrhage rate was 1.6%. Radiation-induced changes were symptomatic in 13.7% and permanent in 2.0% of patients. The statistically significant independent positive predictors of obliteration were no preradiosurgery embolization (p < 0.001), increased prescription dose (p < 0.001), single draining vein (p < 0.001), radiological presence of radiation-induced changes (p = 0.004), and lower Spetzler-Martin grade (p = 0.016). Increased volume and higher Pittsburgh radiosurgery-based AVM score were predictors of postradiosurgery hemorrhage in the univariate analysis only. Clinical deterioration occurred in 30 patients (6.8%), more commonly in patients with postradiosurgery hemorrhage (p = 0.018).
Radiosurgery afforded a reasonable chance of obliteration of unruptured AVMs with relatively low rates of clinical and radiological complications.
颅内未破裂动静脉畸形（AVM）的适当治疗仍存在争议。本研究评估了大量未破裂 AVM 患者接受放射外科治疗的影像学和临床结果。
从他们机构治疗的 1204 例 AVM 患者的前瞻性数据库中，作者确定了 444 例在放射外科治疗前没有破裂证据的患者。患者的平均年龄为 36.9 岁，50%为男性。AVM 病灶的平均体积为 4.2cm³，13.5%位于深部位置，44.4%至少为 Spetzler-Martin 分级 III 级。中位放射外科处方剂量为 20Gy。采用单变量和多变量 Cox 回归分析确定与闭塞、放射外科治疗后出血、放射性改变和放射外科治疗后囊肿形成相关的危险因素。影像学和临床随访的平均时间分别为 76 个月和 86 个月。
AVM 闭塞累积率为 62%，放射外科治疗后年出血率为 1.6%。放射性改变在 13.7%的患者中出现症状，在 2.0%的患者中为永久性改变。闭塞的独立阳性预测因素为放射外科治疗前无栓塞（p<0.001）、增加处方剂量（p<0.001）、单引流静脉（p<0.001）、影像学存在放射性改变（p=0.004）和较低的 Spetzler-Martin 分级（p=0.016）。体积增加和较高的匹兹堡放射外科 AVM 评分仅在单变量分析中是放射外科治疗后出血的预测因素。30 例患者（6.8%）出现临床恶化，放射外科治疗后出血患者更为常见（p=0.018）。
放射外科治疗颅内未破裂 AVM 可获得较高的闭塞率，且临床和影像学并发症发生率相对较低。
