Radiosurgery safe and effective for unruptured intracranial AVMs

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1. In a large series of over 400 patients, the cumulative arteriovenous malformation (AVM) obliteration rate was 62%, with a low rate (2%) of permanent neurological deficit. 

2. Postradiosurgery annual hemorrhage rate was 1.6%, lower than historical annual hemorrhage risk of untreated AVMs (2-4%). 

This study strived to examine the safety and efficacy of radiosurgery for unruptured intracranial AVMs ahead of the on-going A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). The teams retrospective analysis of over 20 years of institutional experience has concluded that radiosurgery is an effective option for obliteration of AVMs with a postradiosurgery hemorrhage risk at or lower than that associated with the natural history of untreated AVMs. There was a 6.8% postradiosurgery morbidity rate in this series, although fully a third of those were due to increased seizure frequency. The study is limited by its single institution, retrospective nature, but given that the on-going randomized control trial of this question has been slow to enroll the requisite number of patients, this large series further bolsters many clinicians’ suspicion that prophylactic treatment of unruptured AVMs via radiosurgery is a viable therapeutic option.

Click to read the study in Journal of Neurosurgery

Click to read an accompanying editorial in Journal of Neurosurgery

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Image: PD

1. In a large series of over 400 patients, the cumulative arteriovenous malformation (AVM) obliteration rate was 62%, with a low rate (2%) of permanent neurological deficit. 

2. Postradiosurgery annual hemorrhage rate was 1.6%, lower than historical annual hemorrhage risk of untreated AVMs (2-4%).

This [retrospective, single-institution ] study identified 444 patients with AVMs from a prospective database spanning 1200 cases who were treated with radiosurgery prior to any evidence of rupture/hemorrhage. Median radiosurgical dose was 20 Gy. Cumulative obliteration rate was 62%. There was a 6.8% postradiosurgery morbidity rate, with cumulative postradiosurgery annual hemorrhage rate of 1.6%, and a 2% rate of permanent neurological deficit follow radiosurgery. Clinical factors significantly associated with successful obliteration include no preradiosurgery embolization, increased radiation dose, presence of a single draining vein, presence of radiation induced changes on radiology, and lower Spetzler-Martin grade.   

In sum: This study strived to examine the safety and efficacy of radiosurgery for unruptured intracranial AVMs ahead of the on-going A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). The teams retrospective analysis of over 20 years of institutional experience has concluded that radiosurgery is an effective option for obliteration of AVMs with a postradiosurgery hemorrhage risk at or lower than that associated with the natural history of untreated AVMs. There was a 6.8% postradiosurgery morbidity rate in this series, although fully a third of those were due to increased seizure frequency. The study is limited by its single institution, retrospective nature, but given that the on-going randomized control trial of this question has been slow to enroll the requisite number of patients, this large series further bolsters many clinicians’ suspicion that prophylactic treatment of unruptured AVMs via radiosurgery is a viable therapeutic option.

Click to read the study in Journal of Neurosurgery 

Click to read an accompanying editorial in Journal of Neurosurgery 

By Allen Ho

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