Contrast-Enhanced Magnetic Resonance Characteristics of Arteriovenous Malformations After Gamma Knife Radiosurgery: Predictors of Post-Angiographic Obliteration Hemorrhage

Neurosurgery 67:101-109, 2010 DOI: 10.1227/01.NEU.0000370601.17570.4

The reported cumulative risk of post-angiographic obliteration (post-AO) hemorrhage from arteriovenous malformations (AVMs) following gamma knife radiosurgery (GKRS) over 10 years is 2.2%.

OBJECTIVE: To identify the warning signs of post-AO hemorrhage by analyzing the characteristics of enhancement on contrast-enhanced MRI magnetic resonance imaging (MRI) of AVMs with post-AO hemorrhage.

METHODS:We performed a retrospective analysis of 121 patients whose AVMs were angiographically obliterated within 5 years of GKRS without hemorrhage and who received at least 1 contrast-enhanced MRI after GKRS (group 1), and 7 patients who experienced post- AO hemorrhage (group 2). We analyzed the enhancement persistence ratio (the percentage of AVMs with persisting enhancement on contrast-enhanced T1-weighted image after obliteration) and the change in size of the enhanced region over time in each patient.

RESULTS: The enhancement persistence ratio showed no significant difference between the 2 groups (89.4% vs 100% for groups 1 and 2, respectively; P = .401). While most cases in group 1 showed a tendency to decrease in size and gradually stabilize following GKRS, there were significantly more cases in group 2 with obvious increment of the enhanced regions within 1 year of angiographic obliteration compared with the previous measurement (4.96% vs 71.4% for groups 1 and 2, respectively; P < .0001).

CONCLUSION: Our results suggest that AVMs that show an increase in the size of the enhanced region within 1 year of angiographic obliteration should be followed up with caution for post-AO hemorrhage. Persisting enhancement itself is not positively associated with subsequent hemorrhage.