Hung Yi-Chieh, Mohammed Nasser, Eluvathingal Muttikkal Thomas Jose, Kearns Kathryn N, Li Chelsea Eileen, Narayan Aditya, Schlesinger David, Xu Zhiyuan, Sheehan Jason P
1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia.
2Division of Neurosurgery, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan.
J Neurosurg. 2019 Aug 30;133(4):1156-1167. doi: 10.3171/2019.5.JNS19722. Print 2020 Oct 1.
The benefits and risks of pre-stereotactic radiosurgery (SRS) embolization have been reported in different studies. The goal of this study was to compare the long-term outcome of arteriovenous malformations (AVMs) treated with and without pre-SRS embolization.
A database including 1159 patients with AVMs who underwent SRS was reviewed. The embolized group was selected by including AVMs with pre-SRS embolization, maximal diameter > 30 mm, and estimated volume > 8 ml. The nonembolized group was defined as AVMs treated by SRS alone with matched de novo nidus volume. Outcomes including incidences of favorable clinical outcome (obliteration without hemorrhage, cyst formation, worsening, or new seizures), obliteration, adverse effects, and angioarchitectural complexity were evaluated.
The study cohort comprised 17 patients in the embolized group (median AVM volume 17.0 ml) and 35 patients in the nonembolized group (median AVM volume 13.1 ml). The rates of obliteration (embolized cohort: 33%, 44%, and 56%; nonembolized cohort: 32%, 47%, and 47% at 4, 6, and 10 years, respectively) and favorable outcome were comparable between the 2 groups. However, the embolized group had a significantly higher incidence of repeat SRS (41% vs 23%, p = 0.012) and total procedures (median number of procedures 4 vs 1, p < 0.001), even with a significantly higher margin dose delivered at the first SRS (23 Gy vs 17 Gy, p < 0.001). The median angioarchitectural complexity score was reduced from 7 to 5 after embolization. Collateral flow and neovascularization were more frequently observed in the embolized nonobliterated AVMs.
Both embolization plus SRS and SRS alone were effective therapies for moderately large (8-39 ml) AVMs. Even with a significantly higher prescription dose at the time of initial SRS, the embolized group still required more procedures to reach final obliteration. The presence of collateral flow and neovascularization could be risk factors for a failure to obliterate following treatment.
不同研究报道了立体定向放射外科手术（SRS）前栓塞的益处和风险。本研究的目的是比较接受和未接受SRS前栓塞治疗的动静脉畸形（AVM）的长期结局。
回顾了一个包含1159例行SRS的AVM患者的数据库。栓塞组选择标准为有SRS前栓塞、最大直径>30mm且估计体积>8ml的AVM。非栓塞组定义为仅接受SRS治疗且初始病灶体积匹配的AVM。评估包括良好临床结局（无出血、囊肿形成、病情恶化或新发癫痫的闭塞）、闭塞、不良反应和血管构筑复杂性等方面的结局。
研究队列包括栓塞组17例患者（中位AVM体积17.0ml）和非栓塞组35例患者（中位AVM体积13.1ml）。两组的闭塞率（栓塞组在4年、6年和10年分别为33%、44%和56%；非栓塞组分别为32%、47%和47%）和良好结局相当。然而，栓塞组重复SRS的发生率显著更高（41%对23%，p = 0.012），且总治疗次数更多（中位治疗次数4次对1次，p < 0.001），即使首次SRS时给予的边缘剂量显著更高（23Gy对17Gy，p < 0.001）。栓塞后血管构筑复杂性评分中位数从7降至5。在栓塞后未闭塞的AVM中更频繁观察到侧支血流和新生血管形成。
栓塞联合SRS和单纯SRS都是治疗中等大小（8 - 39ml）AVM的有效方法。即使初始SRS时处方剂量显著更高，栓塞组仍需要更多治疗次数才能达到最终闭塞。侧支血流和新生血管形成的存在可能是治疗后未能闭塞的危险因素。
