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AVM resection after radiation therapy—clinico-morphological features and microsurgical results

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Abstract

A subgroup of patients initially treated by radiosurgery underwent surgical resection because of recurrent hemorrhage or neurological deterioration. In a retrospective study, we want to analyze the clinical features of these patients and evaluate the effect of microneurosurgery in such rare constellations. Moreover, we hope to find answers about failure of radiation therapy in these cases by correlation of radiobiological and histopathological data. Over a 16-year-period, eight patients with cerebral arteriovenous malformation (AVM) underwent surgical resection, who previously were treated by radiosurgery. The mean duration between radiation therapy and final resection was 7 years. Preoperative evaluation revealed Spetzler–Martin grade III (n = 5) and IV (n = 3) AVMs. Histological examination was achieved in all resected lesions. Mean neurological follow-up was 14 months. Indications for surgical resection were intracerebral hematoma, progressive neurological deficit, and epilepsy. In comparison to the initial angiographic study before radiation therapy, preoperative angiography revealed newly developed “en passant” feeding vessels and stenosis of the main venous drainage in some patients. The mean Rankin score for all patients was 2.75 before and 3.25 after surgical resection. Postoperatively, three patients (38%) developed neurological deterioration. Histological examination of the resected tissue revealed significant radiation-induced pathology in six patients. We did not see correlation between radiation doses and severity of histolopathological radiation-induced changes. Postoperative angiography confirmed total AVM resection in all patients. AVMs insufficiently treated by radiation bear an increased surgical risk. Often, angiographic studies revealed a more complicated morphology. Microsurgical resection was extremely challenging and led to unfavorable outcomes in many of the patients.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany

    Siamak Asgari, Hischam Bassiouni, Dietmar Stolke & Ibrahim Erol Sandalcioglu

  2. Department of Neuroradiology, University Hospital Essen, Essen, Germany

    Elke Gizewski

  3. Department of Pathology and Neuropathology, University Hospital Essen, Essen, Germany

    Johannes A. P. van de Nes

Authors
  1. Siamak Asgari
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  2. Hischam Bassiouni
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  3. Elke Gizewski
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  4. Johannes A. P. van de Nes
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  5. Dietmar Stolke
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  6. Ibrahim Erol Sandalcioglu
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Correspondence to Siamak Asgari.

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Comments

Ludwig Benes, Marburg, Germany

In this retrospective study, Asgari and coworkers comment on a subset of eight AVM patients, out of a group of 440 individuals, who underwent AVM resection in one department, experiencing recurrent hemorrhage or neurological deterioration after initial radiation therapy.

During the last years, not much is written upon this challenging topic, and there are only few substantial management recommendations published in the pertinent literature.

The implication of this study is that AVMs insufficiently treated by radiation therapy hold an increased risk for additional morbidity and mortality not referred to in the Spetzler and Martin grading system. This paper reminds us that hemorrhage during radiation therapy is still a controversy in terms of using repetitive radiation or surgical therapy. Personally, I have good experiences in some individuals suffering from large AVMs with a deeply located part close to the ventricles, when radiation therapy starts with the “ventricular cone” followed by subsequent surgical resection of the superficially located rest of the AVM nidus several months later. In selected patients, this strategy was beneficial in reducing bleeding complications from these AVMs.

This well-written article is an additional and valuable contribution to the controversy of AVM resection after previously performed radiation therapy.

Tatsuki Oyoshi, Zurich, Switzerland

The authors reported eight AVM patients, who underwent AVM resection in their department presenting neurological deterioration or recurrent hemorrhage after initial radiation therapy.

They indicated that microneurosurgical resection for the patient with incompletely treated AVM after initial radiosurgery is very challenging and led to unfavorable outcomes in most cases. Recently, radiotherapy has been advocated in high-risk AVM, such as located in eloquent area, deep seated area, or large size. However, the long-term complications of radiation therapy, including radiation necrosis, cyst formation, hemorrhage, recanalization, increased seizure frequency, and arterial stenosis, occur in some patients who undergo radiation therapy for AVM. This paper would suggest the importance of a selection of treatment modality in high-risk AVM. Of course, follow-up angiography is mandatory for the patients with incompletely treated AVM after radiotherapy.

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Asgari, S., Bassiouni, H., Gizewski, E. et al. AVM resection after radiation therapy—clinico-morphological features and microsurgical results. Neurosurg Rev 33, 53–61 (2010). https://doi.org/10.1007/s10143-009-0216-2

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  • DOI: https://doi.org/10.1007/s10143-009-0216-2

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