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Gamma knife radiosurgery for arteriovenous malformations of basal ganglia, thalamus and brainstem—a retrospective study comparing the results with that for AVMs at other intracranial locations

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Abstract

Objective

The objective of this retrospective study was to study the outcome in patients with basal ganglia, thalamus and brainstem (central/deep) arteriovenous malformations (AVMs) treated with gamma knife radiosurgery (GKS) and to compare the results with that for AVMs at other intracranial locations.

Methods and results

The results of 53 patients with central AVMs and 255 patients with AVMs at other locations treated with GKS at our center between April 1997 and March 2005 with minimum follow-up of 1 year were analyzed.

Central AVMs

Forty of these 53 AVMs were Spetzler-Martin grade III, 11 were grade IV, and 2 were grade V. The mean AVM volume was 4.3 cm3 (range 0.1–36.6 cm3). The mean marginal dose given was 23.3 Gy (range 16–25 Gy). The mean follow-up was 28 months (range 12–96 months). Check angiograms were advised at 2 years after GKS and yearly thereafter in the presence of residual AVM till 4 years. Presence of a residual AVM on an angiogram at 4 years after radiosurgery was considered as radiosurgical failure. Complete obliteration of the AVM was documented in 14 (74%) of the 19 patients with complete angiographic follow-up. Significantly lower obliteration rates (37% vs. 100%) were seen in larger AVMs (>3 cm3) and AVMs of higher (IV and V) Spetzler-Martin grades (28% vs. 100%). The 3- and 4-year actuarial rates of nidus obliteration were 68% and 74%, respectively. Eight patients (15%) developed radiation edema with a statistically significantly higher incidence in patients with AVM volume >3 cm3 and in patients with Spetzler-Martin grade IV and V AVMs. Five patients (9.4%) had hemorrhage in the period of latency.

Comparison of results with AVMs at other locations

Patients with central AVMs presented at a younger age (mean age 22.7 years vs. 29 years), with a very high proportion (81% vs. 63%) presenting with hemorrhage. Significantly higher incidence of radiation edema (15% vs. 5%) and lower obliteration rates (74% vs. 93%) were seen in patients with central AVMs.

Conclusions

GKS is an effective modality of treatment for central AVMs, though relatively lower obliteration rates and higher complication rates are seen compared to AVMs at other locations.

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Acknowledgements

We are thankful to our beloved teachers Dr. P.N. Tandon and Dr. A.K. Banerjee for their valuable suggestions. Our thanks to biophysists Emanuel and Gopi Shankar and statistician Kulwant Singh Kapoor for their help.

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Authors and Affiliations

  1. Department of Neuro Surgery, Neuro Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India, 110029

    Narayanam Anantha Sai Kiran, Shashank Sharad Kale, Manish Kumar Kasliwal, Sandeep Vaishya, Aditya Gupta, Manish Singh Sharma, Bhawani Shankar Sharma & Ashok Kumar Mahapatra

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  1. Narayanam Anantha Sai Kiran
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Correspondence to Shashank Sharad Kale.

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Comment

The authors present a retrospective review of the results of gamma knife treatment of deep (brainstem, thalamic and basal ganglia) AVMs. Fifty-three cases with more than 1-year follow-up were compared with the rest of their cohort, 255 patients with AVMs in less eloquent positions. They showed that these malformations have a lower occlusion rate and higher side effect rate as well as a higher risk of bleeding during the latency period than their less eloquent counterparts.

Rather than focusing on the negative, one has to acknowledge that 74% cure at the “cost” of 15% side effects, only half of which is lasting, is actually a good deal for these patients: the literature demonstrates a higher risk rate with microsurgery in most hands.

There is no explanation why the deep AVMs have a lower occlusion rate than the rest. This may well be a genuine difference in radiosensitivity, but there is an alternative explanation. Despite using the same prescription dose value, the dose may be prescribed to a “tighter” plan in an eloquent area, in effect leaving some parts “undertreated.”

It is also interesting to note the higher risk of hemorrhage in this subgroup. The different angio-architecture and the presence of intranidal aneurysms and venous varices are usually implicated. Analyzing a larger cohort may be correctable for this factor.

Andras A Kemeny

Sheffield, UK

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Kiran, N.A.S., Kale, S.S., Kasliwal, M.K. et al. Gamma knife radiosurgery for arteriovenous malformations of basal ganglia, thalamus and brainstem—a retrospective study comparing the results with that for AVMs at other intracranial locations. Acta Neurochir 151, 1575–1582 (2009). https://doi.org/10.1007/s00701-009-0335-0

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