Treatment of Giant Cerebral Arteriovenous Malformation: Hypofractionated Stereotactic Radiation as the First Stage

Neurosurgery 67:1253–1259, 2010 DOI: 10.1227/NEU.0b013e3181efbaef

Treatment of giant cerebral arteriovenous malformations (AVMs) remains a challenge.

OBJECTIVE: To propose hypofractionated stereotactic radiotherapy (HSRT) as a part of staged treatment, and evaluate its effect by analyzing AVM volume changes.

METHODS: From 2001 to 2007, 20 AVMs larger than 5 cm were treated by HSRT and followed up using magnetic resonance imaging. Patients’ median age was 34 years (8–61 years). Eleven patients presented with hemorrhage and 9 with seizure. Ten patients had previous embolization and radiosurgery had failed in 4. Thirteen AVMs (65%) were classified as Spetzler-Martin grade V and 7 as grade IV. Median pretreatment volume was 46.84 cm3 (12.51-155.38 cm3). Dose was 25 to 30 Gy in 5 to 6 daily fractions. Median follow-up was 32 months.

RESULTS: Median AVM volume decreased to 13.51 cm3 (range, 0.55-147.14 cm3). Residual volume varied from 1.5% to 98%. Volume decreased 44% every year on average. We noted that 6-Gy fractions were more effective (P = .040); embolized AVM tended to respond less (P = .085). After HSRT, we reirradiated 4 AVMs, with 3 amenable to single dose and one with fractions. After HSRT, one patient had an ischemic stroke and one had increased seizure frequency. One AVM bled during follow-up (2.06%/year). No complete obliteration was confirmed.

CONCLUSION: HSRT can turn some giant AVMs manageable for single-dose radiosurgery. Six-Gray fractions were better than 5-Gy and routine embolization seemed unhelpful. There was no increase in bleeding risk with this approach. Future studies with longer follow-up are necessary to confirm our observation.