Kawashima Mariko, Hasegawa Hirotaka, Shin Masahiro, Shinya Yuki, Ishikawa Osamu, Koizumi Satoshi, Katano Atsuto, Nakatomi Hirofumi, Saito Nobuhito
Departments of1Neurosurgery and.
2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.
J Neurosurg. 2020 Dec 4;135(3):733-741. doi: 10.3171/2020.7.JNS201502. Print 2021 Sep 1.
The major concern about ruptured arteriovenous malformations (rAVMs) is recurrent hemorrhage, which tends to preclude stereotactic radiosurgery (SRS) as a therapeutic modality for these brain malformations. In this study, the authors aimed to clarify the role of SRS for rAVM as a stand-alone modality and an adjunct for a remnant nidus after surgery or embolization.
Data on 410 consecutive patients with rAVMs treated with SRS were analyzed. The patients were classified into groups, according to prior interventions: SRS-alone, surgery and SRS (Surg-SRS), and embolization and SRS (Embol-SRS) groups. The outcomes of the SRS-alone group were analyzed in comparison with those of the other two groups.
The obliteration rate was higher in the Surg-SRS group than in the SRS-alone group (5-year cumulative rate 97% vs 79%, p < 0.001), whereas no significant difference was observed between the Embol-SRS and SRS-alone groups. Prior resection (HR 1.78, 95% CI 1.30-2.43, p < 0.001), a maximum AVM diameter ≤ 20 mm (HR 1.81, 95% CI 1.43-2.30, p < 0.001), and a prescription dose ≥ 20 Gy (HR 2.04, 95% CI 1.28-3.27, p = 0.003) were associated with a better obliteration rate, as demonstrated by multivariate Cox proportional hazards analyses. In the SRS-alone group, the annual post-SRS hemorrhage rates were 1.5% within 5 years and 0.2% thereafter and the 10-year significant neurological event-free rate was 95%; no intergroup difference was observed in either outcome. The exclusive performance of SRS (SRS alone) was not a risk for post-SRS hemorrhage or for significant neurological events based on multivariate analyses. These results were also confirmed with propensity score-matched analyses.
The treatment strategy for rAVMs should be tailored with due consideration of multiple factors associated with the patients. Stand-alone SRS is effective for hemorrhagic AVMs, and the risk of post-SRS hemorrhage was low. SRS can also be favorably used for residual AVMs after initial interventions, especially after failed resection.
动静脉畸形破裂（rAVM）最主要的问题是反复出血，这往往使立体定向放射外科治疗（SRS）无法作为这些脑畸形的一种治疗方式。在本研究中，作者旨在阐明SRS作为一种独立治疗方式以及作为手术或栓塞后残留病灶的辅助治疗方式在rAVM治疗中的作用。
分析了410例连续接受SRS治疗的rAVM患者的数据。根据先前的干预措施将患者分为几组：单纯SRS组、手术联合SRS组（Surg-SRS组）和栓塞联合SRS组（Embol-SRS组）。将单纯SRS组的结果与其他两组进行比较分析。
Surg-SRS组的闭塞率高于单纯SRS组（5年累积率97%对79%，p<0.001），而Embol-SRS组与单纯SRS组之间未观察到显著差异。多因素Cox比例风险分析表明，先前的切除术（风险比[HR]1.78，95%置信区间[CI]1.30 - 2.43，p<0.001）、最大动静脉畸形直径≤20 mm（HR 1.81，95% CI 1.43 - 2.30，p<0.001）以及处方剂量≥20 Gy（HR 2.04，95% CI 1.28 - 3.27，p = 0.003）与更好的闭塞率相关。在单纯SRS组中，SRS后5年内的年出血率为1.5%，之后为0.2%，10年无重大神经事件发生率为95%；在这两个结果中均未观察到组间差异。基于多因素分析，单纯SRS（仅SRS）的单独应用不是SRS后出血或重大神经事件的风险因素。倾向评分匹配分析也证实了这些结果。
rAVM的治疗策略应在充分考虑与患者相关的多个因素的基础上进行调整。单纯SRS对出血性动静脉畸形有效，且SRS后出血风险较低。SRS也可有效地用于初始干预后的残留动静脉畸形，尤其是在切除失败后。
