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Volumetric Analysis of Intracranial Arteriovenous Malformations Contoured for CyberKnife Radiosurgery With 3-Dimensional Rotational Angiography vs Computed Tomography/Magnetic Resonance Imaging

Veeravagu, Anand MD; Hansasuta, Ake MD§; Jiang, Bowen MD; Karim, Aftab S. MD; Gibbs, Iris C. MD; Chang, Steven D. MD

doi: 10.1227/01.neu.0000430285.00928.30
Research-Human-Clinical Studies

BACKGROUND: Accurate target delineation has significant impact on brain arteriovenous malformation (AVM) obliteration, treatment success, and potential complications of stereotactic radiosurgery.

OBJECTIVE: We compare the nidal contouring of AVMs using fused images of contrasted computed tomography (CT) and magnetic resonance imaging (MRI) with matched images of 3-dimensional (3-D) cerebral angiography for CyberKnife radiosurgery (CKRS) treatment planning.

METHODS: Between May 2009 and April 2012, 3-D cerebral angiography was integrated into CKRS target planning for 30 consecutive patients. The AVM nidal target volumes were delineated using fused CT and MRI scans vs fused CT, MRI, and 3-D cerebral angiography for each patient.

RESULTS: The mean volume of the AVM nidus contoured with the addition of 3-D cerebral angiography to the CT/MRI fusion (9.09 cm3, 95% confidence interval: 5.39 cm3-12.8 cm3) was statistically smaller than the mean volume contoured with CT/MRI fused scans alone (14.1 cm3, 95% confidence interval: 9.16 cm3-19.1 cm3), with a mean volume difference of δ = 5.01 cm3 (P = .001). Diffuse AVM nidus was associated with larger mean volume differences compared with a compact nidus (δ = 6.51 vs 2.11 cm3, P = .02). The mean volume difference was not statistically associated with the patient's sex (male δ = 5.61, female δ = 5.06, P = .84), previous hemorrhage status (yes δ = 5.69, no δ = 5.23, P = .86), or previous embolization status (yes δ = 6.80, no δ = 5.95, P = .11).

CONCLUSION: For brain AVMs treated with CKRS, the addition of 3-D cerebral angiography to CT/MRI fusions for diagnostic accuracy results in a statistically significant reduction in contoured nidal volume compared with standard CT/MRI fusion-based contouring.

ABBREVIATIONS: AVM, arteriovenous malformation

CKRS, CyberKnife radiosurgery

DSA, digital subtraction angiography

MRA, magnetic resonance angiography

SRS, stereotactic radiosurgery

Departments of Neurological Surgery, Stanford University School of Medicine, Stanford, California;

Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California;

§Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Correspondence: Steven D. Chang, MD, Department of Neurological Surgery, Stanford University, 300 Pasteur Drive, R205, Stanford, CA 94305. E-mail:

Received October 04, 2012

Accepted March 19, 2013

Copyright © by the Congress of Neurological Surgeons