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Treatment of AVM: Stereotactic Radiosurgery

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Brain Arteriovenous Malformations

Abstract

The role of radiosurgery in the management of arteriovenous malformations (AVMs) is well established. Optimal treatment modality for AVMs should be decided by multi-disciplinary teams, and radiosurgeons are recommended to be integral part of such a team. The decision making process will consider a range of patient, lesion and institution specific factors. Patient factors include presentation, age, clinical state, gender and patient preferences. Lesion specific factors are location of the AVM, its size, the pattern of venous drainage, the feeding arterial supply, the shape of the nidus, and other dynamic angio-architectural features that are best studied by DSA. The goals of pre-treatment consultation are to adequately inform and consent the patient, and to assess any particular issues that could impact on treatment delivery. The rate of thrombo-obliteration is 60–80%, which typically occurs within 4 years after radiosurgical treatment. It primarily depends on the marginal dose delivered to the edge of the AVM, and on lesion volume. As the primary aim of any AVM treatment is the complete elimination of the pathological arteriovenous shunt, in the case of incomplete obliteration several salvage treatments are available. These include surgical resection and embolization of the residual nidus in selected cases, and a second radiosurgical treatment leading to obliteration of two third of eligible lesions. The rate of permanent radiation induced complications is approximately 4% in unselected patient population, determined by prescribed radiation dose, prescription isodose volume and location. The rate of late complications like cyst formation, radiation necrosis or secondary tumors is exceedingly low. Bleeding risk and the risk of its resulting morbidity/mortality is not increased compared with untreated lesions during the latency period until full obliteration. Approximately 30% of AVM patients present with seizures, and the rate is even higher in large AVMs. Although seizure control is not the primary aim of radiosurgery, 44–69% of epileptic patients become seizure free after radiosurgery, which is a compatible rate of seizure freedom after microsurgery. Controversial issues of AVM radiosurgery, such as treatment of large AVMs, prior embolization and treating unruptured AVMs are also discussed. Even AVMs larger than 10 cm3 can now be treated by staged-volume radiosurgery resulting in an obliteration rate of approximately 60% with acceptable morbidity. Embolization before radiosurgery may be considered to secure a flow aneurysm, or if a significant segmental volume reduction can be realistically achieved. However, an ill-considered embolization resulting in a patchy deposition of embolic material that may make radiosurgery less efficacious together with additional procedural risks is not recommended. Based on the low rate of cumulative morbidity and mortality together with high rate of 5-year obliteration after contemporary radiosurgery, and with available data on natural history, a follow-up duration of 15–20 years is expected to realize benefits of radiosurgery for selected patients with unruptured AVMs.

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Authors and Affiliations

  1. Department of Functional Neurosurgery, National Institute of Clinical Neurosciences, Amerikai út 57, Budapest, 1145, Hungary

    Gábor Nagy M.D., Ph.D.

  2. Department of Neurosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK

    Jeremy G. Rowe M.A., D.M., F.R.C.S. & Matthias W. R. Radatz M.D., F.R.C.S.

  3. National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK

    Jeremy G. Rowe M.A., D.M., F.R.C.S. & Matthias W. R. Radatz M.D., F.R.C.S.

  4. Thornbury Radiosurgery Centre, Sheffield, UK

    Jeremy G. Rowe M.A., D.M., F.R.C.S. & Matthias W. R. Radatz M.D., F.R.C.S.

Authors
  1. Gábor Nagy M.D., Ph.D.
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  2. Jeremy G. Rowe M.A., D.M., F.R.C.S.
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  3. Matthias W. R. Radatz M.D., F.R.C.S.
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Correspondence to Gábor Nagy M.D., Ph.D. .

Editor information

Editors and Affiliations

  1. Department of Neurosurgery and Neuro-oncology, Institute of Clinical Neurosciences, Military University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic

    Vladimír Beneš

  2. Department of Neurosurgery and Neuro-oncology, Institute of Clinical Neurosciences, Military University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic

    Ondřej Bradáč

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Nagy, G., Rowe, J.G., Radatz, M.W.R. (2017). Treatment of AVM: Stereotactic Radiosurgery. In: Beneš, V., Bradáč, O. (eds) Brain Arteriovenous Malformations. Springer, Cham. https://doi.org/10.1007/978-3-319-63964-2_11

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  • DOI: https://doi.org/10.1007/978-3-319-63964-2_11

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  • Online ISBN: 978-3-319-63964-2

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