Stereotactic Radiosurgery with Neoadjuvant Embolization of Larger Arteriovenous Malformations: An Institutional Experience

Richard Dalyai,L Fernando Gonzalez,Robert H Rosenwasser,George Ghobrial,Nohra Chalouhi,Thana Theofanis,Pascal Jabbour,David S Gordon,Robert M Starke,Stavropoula I Tjoumakaris,Aaron S Dumont

doi:10.1155/2014/306518

Richard Dalyai, L Fernando Gonzalez + Show 9 more

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https://doi.org/10.1155/2014/306518

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Abstract

Objective. This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs. Methods. Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011. Results. The median volume of AVM in this series was 28 cm3 and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9–136 months). Overall procedural complications occurred in 14 patients. There were 13 minor neurologic complications and 1 major complication (due to embolization) while four patients had posttreatment hemorrhage. Thirty-eight patients (40%) were cured radiographically. The postradiosurgery actuarial rate of obliteration was 45% at 5 years, 56% at 7 years, and 63% at 10 years. In multivariate analysis, larger AVM size, deep venous drainage, and the increasing number of embolization/SRS sessions were negative predictors of obliteration. The number of embolizations correlated positively with the number of stereotactic radiosurgeries (P < 0.005). Conclusions. Multimodality endovascular and radiosurgical approach is an efficacious treatment strategy for large AVM.

Highlights

Cerebral arteriovenous malformations (AVM) are rare but potentially devastating vascular lesions that often affect young adults
Surgical excision is the mainstay of treatment for Spetzler-Martin (SM) grade I and II AVM
We have explored a multimodality therapy of initial endovascular embolization for AVM volume reduction followed by stereotactic radiosurgery (SRS) to treat the remaining nidus

Summary

Introduction

Cerebral arteriovenous malformations (AVM) are rare but potentially devastating vascular lesions that often affect young adults. Because of high procedural morbidity rates, surgery is avoided in larger and higher grade AVM, and alternative therapies are often considered for these lesions. Radiosurgery, initially conceived by Leksell [2] in 1968, is a well-established treatment alternative to surgical resection for intracranial AVM. Stand-alone stereotactic radiosurgery (SRS) may have limited utility for larger AVM [3]. For these larger lesions, we have explored a multimodality therapy of initial endovascular embolization for AVM volume reduction followed by SRS to treat the remaining nidus. By reducing the size of the nidus targeted by SRS, endovascular embolization is thought to improve AVM obliteration rates while minimizing SRS-related complications. We report our 15year experience in managing these challenging lesions with a combined embolization and SRS approach

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