Ding Dale, Xu Zhiyuan, Shih Han-Hsun, Starke Robert M, Yen Chun-Po, Sheehan Jason P
Department of Neurological Surgery, Charlottesville, Virginia, USA.
Department of Neurological Surgery, Charlottesville, Virginia, USA; Department of Anesthesiology, Taichung, Taiwan, Republic of China.
World Neurosurg. 2016 Jan;85:263-72. doi: 10.1016/j.wneu.2015.10.001. Epub 2015 Oct 13.
Incomplete microsurgical resection of cerebral arteriovenous malformations (AVM) occurs uncommonly. However, such patients harboring postoperative residual nidi remain exposed to the risk of AVM hemorrhage and are therefore reasonable candidates for further intervention. The goals of this retrospective case-control study are to analyze the radiosurgery outcomes for partially resected AVMs and determine the effect of prior resection on AVM radiosurgery outcomes.
We evaluated a prospective database of AVM patients treated with radiosurgery from 1989-2013. Previously resected AVMs with radiologic follow-up ≥2 years or nidus obliteration were selected for analysis and matched, in a 1:1 fashion and blinded to outcome, to previously unresected AVMs. Statistical analyses were performed to assess relationship between prior resection and AVM radiosurgery outcomes.
The matching process yielded 88 patients in each of the previously resected and unresected AVM cohorts. In the resected AVM cohort, the actuarial AVM obliteration rates at 3 and 5 years were 47% and 75%, respectively; the rates of radiologic and symptomatic radiation-induced changes (RICs) were 10% and 3%, respectively; and the annual postradiosurgery hemorrhage risk was 1.1%. The lack of prior AVM resection (P < 0.001) and superficial AVM location (P = 0.009) were independent predictors of radiologic RIC. The actuarial rates of obliteration (P = 0.849) and postradiosurgery hemorrhage (P = 0.548) were not significantly different between the resected and unresected AVM cohorts.
Radiosurgery affords a reasonable risk-to-benefit profile for incompletely resected AVMs. For those with a small-volume residual nidus after resection, radiosurgery should be considered an effective alternative to repeat resection.
大脑动静脉畸形（AVM）的显微手术切除不完全较为少见。然而，这类术后残留病灶的患者仍面临AVM出血风险，因此是进一步干预的合理候选对象。这项回顾性病例对照研究的目的是分析部分切除的AVM的放射外科治疗结果，并确定先前切除对AVM放射外科治疗结果的影响。
我们评估了1989年至2013年接受放射外科治疗的AVM患者的前瞻性数据库。选择先前切除且放射学随访≥2年或病灶闭塞的AVM进行分析，并以1:1的方式与先前未切除的AVM进行匹配，且对结果设盲。进行统计分析以评估先前切除与AVM放射外科治疗结果之间的关系。
匹配过程在先前切除和未切除的AVM队列中各产生了88名患者。在切除的AVM队列中，3年和5年的精算AVM闭塞率分别为47%和75%；放射学和有症状的放射诱导变化（RIC）率分别为10%和3%；放射外科治疗后每年的出血风险为1.1%。先前未进行AVM切除（P < 0.001）和AVM位于浅表部位（P = 0.009）是放射学RIC的独立预测因素。切除和未切除的AVM队列之间的闭塞精算率（P = 0.849）和放射外科治疗后出血率（P = 0.548）无显著差异。
放射外科为不完全切除的AVM提供了合理的风险效益比。对于切除后残留小体积病灶的患者，放射外科应被视为重复切除的有效替代方法。
