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Radiosurgery for Primary Motor and Sensory Cortex Arteriovenous Malformations: Outcomes and the Effect of Eloquent Location

Ding, Dale MD; Yen, Chun-Po MD; Xu, Zhiyuan MD; Starke, Robert M. MD, MSc; Sheehan, Jason P. MD, PhD

doi: 10.1227/NEU.0000000000000106
Research-Human-Clinical Studies

BACKGROUND: Eloquent intracranial arteriovenous malformations (AVMs) located in the primary motor or somatosensory cortex (PMSC) carry a high risk of microsurgical morbidity.

OBJECTIVE: To evaluate the outcomes of radiosurgery on PMSC AVMs and compare them with radiosurgery outcomes in a matched cohort of noneloquent lobar AVMs.

METHODS: Between 1989 and 2009, 134 patients with PMSC AVMs underwent Gamma Knife radiosurgery with a median radiographic and clinical follow-up of 64 and 80 months, respectively. Seizure (40.3%) and hemorrhage (28.4%) were the most common presenting symptoms. Pre-radiosurgery embolization was performed in 33.6% of AVMs. Median AVM volume was 4.1 mL (range, 0.1-22.6 mL), and prescription dose was 20 Gy (range, 7-30 Gy). Cox regression analysis was performed to identify factors associated with obliteration.

RESULTS: The overall obliteration rate, including magnetic resonance imaging and angiography, after radiosurgery was 63%. Obliteration was achieved in 80% of AVMs with a volume less than 3 mL compared with 55% for AVMs larger than 3 mL. No previous embolization (P = .002) and a single draining vein (P = .001) were independent predictors of obliteration on multivariate analysis. The annual post-radiosurgery hemorrhage risk was 2.5%. Radiosurgery-related morbidity was temporary and permanent in 14% and 6% of patients, respectively. Comparing PMSC AVMs with matched noneloquent lobar AVMs, the obliteration rates and clinical outcomes after radiosurgery were not statistically different.

CONCLUSION: For patients harboring PMSC AVMs, radiosurgery offers a reasonable chance of obliteration with a relatively low complication rate. Eloquent location does not appear to confer the same negative prognostic value for radiosurgery that it does for microsurgery.

ABBREVIATIONS: AVM, arteriovenous malformation

DSA, digital subtraction angiography

PMSC, primary motor or somatosensory cortex

RIC, radiation-induced change

Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia

Correspondence: Jason Sheehan, MD, PhD, Department of Neurological Surgery, University of Virginia, P.O. Box 800212, Charlottesville, VA 22908. E-mail: jps2f@hscmail.mcc.virginia.edu

Received March 11, 2013

Accepted July 11, 2013

Copyright © by the Congress of Neurological Surgeons