多中心国际联盟评估立体定向放射外科治疗脑硬脑膜动静脉瘘。
Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium.
机构信息
1Department of Neurological Surgery, University of Miami, Florida.
2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.
出版信息
J Neurosurg. 2020 Jan 1;132(1):114-121. doi: 10.3171/2018.8.JNS181467. Epub 2019 Jan 4.
OBJECTIVE
In this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome.
METHODS
Data from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose.
RESULTS
A mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5-18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration.
CONCLUSIONS
GKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.
目的
在这项多中心研究中，作者回顾了接受伽玛刀放射外科治疗硬脑膜动静脉瘘（dAVF）的患者的结果，并确定了预后的预测因素。
方法
从国际伽玛刀研究基金会的一组 114 名接受脑 dAVF 伽玛刀放射外科治疗的患者中收集数据。良好的结果定义为 dAVF 闭塞，无治疗后出血或永久性症状性放射性诱导并发症。通过多变量逻辑回归分析评估患者和 dAVF 特征，以确定预后的预测因素；在竞争风险生存分析中计算 dAVF 无闭塞的概率；使用 Youden 指数确定最佳放射外科剂量。
结果
平均边缘剂量为 21.8Gy。平均随访时间为 4 年（0.5-18 年）。总的闭塞率为 68.4%。放射外科后 3、5、7 和 10 年的闭塞累积发生率分别为 41.3%、61.1%、70.1%和 82.0%。4 例患者（年风险 0.9%）发生放射外科后出血。10.4%的患者出现放射性影像学改变；5.2%有症状，3.5%有永久性损害。63.2%的患者取得了良好的结果。中颅窝和天幕 dAVF 患者（OR 2.4，p=0.048）和接受边缘剂量大于 23Gy 的患者（OR 2.6，p=0.030）不太可能取得良好的结果。常用的分级量表（如 Borden 和 Cognard）不能预测结果。女性（OR 1.7，p=0.03）、无静脉扩张（OR 3.4，p<0.001）和海绵窦颈动脉位置（OR 2.1，p=0.019）是伽玛刀治疗引起的 dAVF 闭塞的预测因素。
结论
伽玛刀治疗脑 dAVF 可使大多数患者闭塞，并避免永久性并发症。那些海绵窦颈动脉位置且无静脉扩张的患者，放射外科后更有可能闭塞瘘。常用的分级量表不能可靠地预测放射外科后的结果。
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