Marciscano Ariel E, Huang Judy, Tamargo Rafael J, Hu Chen, Khattab Mohamed H, Aggarwal Sameer, Lim Michael, Redmond Kristin J, Rigamonti Daniele, Kleinberg Lawrence R
Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Neurosurgery. 2017 Jul 1;81(1):136-146. doi: 10.1093/neuros/nyw041.
There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS).
To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs.
Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected.
Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated ( P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year.
Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.
对于无法手术的高级别动静脉畸形（AVM）的最佳治疗方案尚无共识。这项针对42例高级别AVM患者的长期研究报告了使用计划性多阶段重复立体定向放射外科治疗（SRS）的闭塞率和不良事件（AE）发生率。
评估多阶段SRS的疗效和安全性，即在每次治疗时对整个AVM病灶进行治疗，以实现高级别AVM的完全闭塞。
1989年至2013年期间，对高级别斯佩茨勒-马丁（S-M）III-V级AVM患者进行至少2次多阶段SRS治疗。收集闭塞率、轻微/严重AE以及治疗特征等临床结果。
42例患者符合纳入标准（26例S-M III级；13例S-M IV级；3例S-M V级），首次SRS后中位随访时间为9.5年。SRS治疗阶段的中位数为2，阶段之间的中位间隔为3.5年。22例患者在SRS前接受了栓塞治疗。AVM完全闭塞率为38%，闭塞的中位时间为9.7年。多因素分析显示，较高的S-M级别与未能实现闭塞显著相关（P = 0.04）。观察到27例SRS后AE，SRS后颅内出血率为每位患者每年0.027次事件。
多阶段SRS治疗高级别AVM可使相当一部分患者实现AVM闭塞，且AE发生率可接受。较低的闭塞率与较高的S-M级别和SRS前栓塞治疗有关。由于部分闭塞并不能预防出血，应谨慎考虑这种方法。
