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Evaluation of prognostic factors as predictor of AVMS obliteration after Gamma Knife radiosurgery

  • Clinical Article - Vascular
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Abstract

Background

The reported AVMs obliteration rate after Gamma Knife radiosurgery (GKS) ranges from 70 to 94 %. The objective of the present study was to assess prognostic factors predictive for cerebral AVMs obliteration in 127 patients who underwent GKS.

Methods

The AVMs were classified according to the Spetzler-Martin classification. Twenty-one cases (16.5 %) were classified as grade I, 46 cases (36.2 %) as grade II, 51 cases (40.1 %) as grade III, and nine cases (7.1 %) as grade IV–V. The AVMs were deeply located in 16.5 % of patients. The peripheral prescription dose ranged from 16 to 30 Gy (mean 22.3 Gy). The AVMs volume ranged from 0.1 to 13 cc (mean 2.7 cc).

Results

In 72 patients out of the 104 (69.2 %) with a radiological follow-up, MRI showed the AVM obliteration; in 54 cases (60 %) out of the 90 that performed a DSA, a complete AVM obliteration was achieved (average closure time 48.5 months). The volume of the nidus (p = 0.001), the prescription dose (p = 0.004), the 2002 Pollock–Flickinger classification (p = 0.031), and their 2008 revised classification (p = 0.025) were found to be statistically significant in predicting the probability of AVM closure. In the multivariate analysis, only the prescription dose was found to be an independent prognostic factor (p = 0.009) for AVM obliteration.

Conclusions

The volume of the nidus and the prescription dose significantly influence the outcome of radiosurgical treatment. The Pollock–Flickinger classification was found to be a reliable scoring system in predicting the AVM closure and an important tool for selection of patients candidate for GKS.

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Authors and Affiliations

  1. Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Via Olgettina 60, 20132, Milan, Italy

    Alberto Franzin, Silvia Snider, Nicola Boari, Piero Picozzi, Giorgio Spatola, Filippo Gagliardi & Pietro Mortini

  2. Service of Neuroradiology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy

    Francesco Scomazzoni

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  1. Alberto Franzin
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  2. Silvia Snider
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  3. Nicola Boari
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  4. Francesco Scomazzoni
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Correspondence to Alberto Franzin.

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Comment

Radiosurgery of AVMs is still a challenge to the radio surgical community, with results ranging from no obliteration to obliteration to the development of adverse radiation effects. This explains the need for predictors of outcome in order to properly select patients who may benefit from radiosurgery. Previous studies have identified nidus volume, patient age, location, venous drainage pattern, and previous embolization as predictors of outcome. Various AVM grading systems relevant to radiosurgery have been based on combinations of those parameters. The authors present a retrospective review of their own data searching for predictors of obliteration. In this study, nidus volume, radiation dose, and AVM classification according to Pollock-Flickinger were the sole predictors of AVM obliteration following first-time, single-stage Gamma Knife radiosurgery. Nidus volume was the only independent predictor of AVM obliteration in this study. This is not surprising, since radiation dose depends mainly on nidus volume provided that radiation dose follows international standards. The authors have identified a cut-off nidus volume separating obliterated from non-obliterated cases. Nidus volumes of up to 3 cc were highly more likely to be associated with AVM obliteration than larger nidus volumes. In two older studies, the probability of obliteration was also volume dependent with smaller volumes being more likely to obliterate. According to the literature and the findings of this study, there seem to be three volume ranges of the AVM nidus relevant for radiosurgery: <3 cc, 3–10 cc, and >10 cc. An AVM nidus of <3 cc seems to respond with a high obliteration rate to single-stage radiosurgery, an AVM nidus of >10 cc seems to respond significantly less likely with obliteration, and the obliteration rate of an AVM nidus of 3–10 cc seems to be somewhere in between. This should be kept in mind when selecting patients with AVMs for radiosurgery. This study contributes to our understanding of radio surgical treatment of AVMs and to the goal of minimizing individual patients’ risks and optimizing treatment results.

Thomas Mindermann

Zurich, Switzerland

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Franzin, A., Snider, S., Boari, N. et al. Evaluation of prognostic factors as predictor of AVMS obliteration after Gamma Knife radiosurgery. Acta Neurochir 155, 619–626 (2013). https://doi.org/10.1007/s00701-013-1631-2

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