Third Stereotactic Radiosurgery for Residual Arteriovenous Malformations: A Retrospective Multicenter Study

Stylianos Pikis; Georgios Mantziaris; Chloe Dumot; Ahmed Shaaban; Maria Protopapa; Zhiyuan Xu; Ajay Niranjan; Zhishuo Wei; Priyanka Srinivasan; Lilly W Tang; Roman Liscak; Jaromir May; Nuria Martinez Moreno; Roberto Martinez Álvarez; Selcuk Peker; Yavuz Samanci; Ahmed M Nabeel; Wael A Reda; Sameh R Tawadros; Khaled Abdelkarim; Amr M N El-Shehaby; Reem M Emad; Ahmed Hesham Elazzazi; Varun Padmanaban; Francis J Jareczek; James McInerney; Kevin M Cockroft; Dade Lunsford; Jason P Sheehan

doi:10.1227/neu.0000000000002805

Third Stereotactic Radiosurgery for Residual Arteriovenous Malformations: A Retrospective Multicenter Study

Neurosurgery. 2023 Dec 18. doi: 10.1227/neu.0000000000002805. Online ahead of print.

Authors

Stylianos Pikis^{1

2}, Georgios Mantziaris¹, Chloe Dumot^{1

3}, Ahmed Shaaban¹, Maria Protopapa², Zhiyuan Xu¹, Ajay Niranjan⁴, Zhishuo Wei⁴, Priyanka Srinivasan⁴, Lilly W Tang⁴, Roman Liscak⁵, Jaromir May⁵, Nuria Martinez Moreno⁶, Roberto Martinez Álvarez⁶, Selcuk Peker⁷, Yavuz Samanci⁷, Ahmed M Nabeel^{8

9}, Wael A Reda^{8

9}, Sameh R Tawadros^{8

10}, Khaled Abdelkarim^{8

10}, Amr M N El-Shehaby^{8

10}, Reem M Emad^{8

11}, Ahmed Hesham Elazzazi¹⁰, Varun Padmanaban¹², Francis J Jareczek¹², James McInerney¹², Kevin M Cockroft¹², Dade Lunsford⁴, Jason P Sheehan¹

Affiliations

¹ Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
² Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece.
³ Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France.
⁴ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
⁵ Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
⁶ Radiosurgery Unit, Hospital Ruber Internacional, Madrid, Spain.
⁷ Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey.
⁸ Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.
⁹ Neurosurgery Department, Benha University, Qalubya, Egypt.
¹⁰ Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt.
¹¹ Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
¹² Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.

PMID: 38108313
DOI: 10.1227/neu.0000000000002805

Abstract

Background and objectives: There are no studies evaluating the efficacy and safety of more than 2 stereotactic radiosurgery (SRS) procedures for cerebral arteriovenous malformations (AVM). The aim of this study was to provide evidence on the role of third single-session SRS for AVM residual.

Methods: This multicenter, retrospective study included patients managed with a third single-session SRS procedure for an AVM residual. The primary study outcome was defined as AVM nidus obliteration without AVM bleeding or symptomatic radiation-induced changes (RIC). Secondary outcomes evaluated were AVM obliteration, AVM hemorrhage, asymptomatic, and symptomatic RIC.

Results: Thirty-eight patients (20/38 [52.6%] females, median age at third SRS 34.5 [IQR 20] years) were included. The median clinical follow-up was 46 (IQR 14.8) months, and 17/38 (44.7%) patients achieved favorable outcome. The 3-year and 5-year cumulative probability rates of favorable outcome were 23% (95% CI = 10%-38%) and 53% (95% CI = 29%-73%), respectively. The cumulative probability of AVM obliteration at 3 and 5 years after the third SRS was 23% (95% CI = 10%-37%) and 54% (95% CI = 29%-74%), respectively. AVM bleeding occurred in 2 patients, and 1 of them underwent subsequent resection. The cumulative probability rate of post-SRS AVM hemorrhage remained constant at 5.3% (95% CI = 1%-16%) during the first 5 years of follow-up. Transient symptomatic RIC managed conservatively occurred in 5/38 patients (13.2%) at a median time of 12.5 (IQR 22.5) months from third SRS. Radiation-induced cyst formation was noted in 1 patient (4.2%) 19 months post-SRS. No mortality, radiation-associated malignancy, or permanent symptomatic RIC was noted during follow-up.

Conclusion: A third single-session SRS to treat a residual intracranial AVM offers obliteration in most patients. The risk of RIC was low, and these effects were transient. While not often required, a third SRS can be performed in patients with persistent residual AVMs.