Article
CyberKnife radiosurgery provides acceptable longterm control with low risk of rebleeding in arteriovenous malformations
CyberKnife Radiochirurgieals nicht-invasive Therapiealternative von Arteriovenösen Malformationen zurlangfristigen Kontrolle beiniedrigen Re-Blutungsraten
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Published: | May 8, 2019 |
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Objective: Cerebral arteriovenous malformations (AVMs) are rare vascular lesions potentially responsible for substantial neurological morbidity and mortality. The treatment of AVMs is complex, often based on multimodal interventions combining endovascular treatment, microsurgical resection and stereotactic radiosurgery. However, definitive reports on the results of combined treatment of AVM are still lacking. Here we report on the clinical and radiographic results and rebleeding rates after CyberKnife radiosurgery alone and in combination with embolization in a large multi-institutional AVM cohort.
Methods: We retrospectively analyzed 132 patients with AVMs (Spetzler-Martin (SM) grades 2-6) treated in two institutions (Charité Universitätsklinikum Berlin, Germany and Messina, Italy) with single-fraction CyberKnife radiosurgery between 2007 and 2018. Criteria for treatment were deep or critical location, large size (nidus diameter >5cm), or patient preference for unruptured AVMs. All patients underwent multislice computed tomography and 3D-volumetric CT-angiography and well as 3D- digital subtraction angiography and 3D MR angiography for treatment planning. Single-fraction doses between 14 – 22 Gy (median 18 Gy) were applied to the 85% isodose line. Embolization was performed before radiosurgery in 55 cases (41.6%).
Results: Median age of the population was 39.8 yrs (range 9–72 yrs). Median follow-up was 51 months (range 3–74 months). Complete obliteration was achieved in 68 (51.5%), partial remission in 24 cases (18.2%), while minimal response or no change were observed in 23 cases (17.4%). Obliteration rate in the 65 patients with longer than 4 years follow-up was 86.2%. Treatment induced toxicity (radiation necrosis and/or edema requiring prolonged steroid treatment) was observed in 23 cases (17.4%), while 109 patients (82.5%) remained symptom-free. Rebleeding occurred in 4 cases (3.0%) and 2 patients died during follow-up (1.51%), with 1 death was associated with rebleeding from the previously radiated AVM (0.75%).
Conclusion: CyberKnife radiosurgery presents a valid therapeutic approach in AVMs with acceptable obliteration rates, low toxicity and rare incidence of rebleeding.