Franziska Loebel, Antonio Pontoriero, Anne Kluge, Giuseppe Iatì, Gueliz Acker, Markus Kufeld, Alberto Cacciola, Stefano Pergolizzi, Sergio Vinci, Sara Lillo, Ran Xu, Carmen Stromberger, Volker Budach, Peter Vajkoczy, Carolin Senger, Alfredo Conti
Abstract
Cerebral arteriovenous malformations (AVMs) are challenging lesions, often requiring multimodal interventions; however, data on the efficacy of stereotactic radiosurgery for cerebral AVMs are limited. This study aimed to evaluate the clinical and radiographic results following robotic radiosurgery, alone or in combination with endovascular treatment, and to investigate factors associated with obliteration and complications in patients with AVM.
Introduction
Cerebral arteriovenous malformations (AVMs) are complex neurovascular lesions exhibiting an abnormal communication between arterial feeders and draining veins. Due to abnormal vascular structure and altered blood flow dynamics, there is an increased risk of intracranial hemorrhage, potentially leading to substantial neurological morbidity and mortality at rates of 2–4% per year [1–3]. AVM treatment remains controversial, and individualized treatment strategies comprise microsurgical resection, endovascular treatment, and/or stereotactic radiosurgery (SRS), in addition to watchful waiting [4]. Complete obliteration is the only strategy to abrogate the risk of AVM bleeding. While small AVMs in non-eloquent brain areas are best managed with complete microsurgical resection, more complex malformations (those with a grade of IV–V according to the Spetzler-Martin (SM) classification [5] are usually considered inoperable due to their eloquent localization or deep venous drainage.
Materials & Methods
Study design
We retrospectively analyzed clinical and radiographic data of 123 patients with AVMs of all SM grades treated between 2007 and 2018 at two academic institutions (Charité Universitaetsmedizin Berlin, Germany, and Università degli studi di Messina, Italy). The study was approved by the local ethics committees (EA1/233/18 and Comitato etico Messina Prot. 34/19).
Results
Between 2007 and 2018, 123 patients with AVMs were treated by CKRS. The median age at CKRS initiation was 39.8 years (range, 9.0–76.0) years. The ratio of males (62) to females (61) was balanced. The median mRS was 2 (range, 1–4). Initially, 68 (55.3%) patients presented with an intracerebral hemorrhage; the others were diagnosed with AVMs following complaints of headaches, epileptic seizures, and motor or sensory deficits. In some cases, diagnosis was incidental.
Discussion
Although microsurgical resection remains the standard for treating intracranial AVMs, deep-seated or higher-grade lesions remain major neurosurgical challenges.
The 123 patients treated by CKRS for AVMs demonstrated satisfactory outcomes, with complete and partial obliteration achieved in 56.8% and 26.3% of cases, respectively; in those with follow-up times exceeding four years, the rates were 72.8% and 11.9%, respectively. The rate of complete obliteration was significantly higher in the LG than in the HG subgroup, and only 4.2% of the patients experienced recurrent hemorrhage or treatment-related toxicity.
Citation: Loebel F, Pontoriero A, Kluge A, Iatì G, Acker G, Kufeld M, et al. (2022) Image-guided robotic radiosurgery for the treatment of arteriovenous malformations. PLoS ONE 17(9): e0266744. https://doi.org/10.1371/journal.pone.0266744
Editor: Robert Jeenchen Chen, Stanford University School of Medicine, UNITED STATES
Received: June 19, 2021; Accepted: March 26, 2022; Published: September 22, 2022
Copyright: © 2022 Loebel et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data is be held in a public repository: https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/08XPTK.
Funding: The funding for the study was provided solely by the academic institutions mentioned, and there was no commercial funding organization. The funding institutions provided support in the form of salaries for the authors, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contribution section’.
Competing interests: There are no Competing Interests for this study. A,C, serves as a scientific consultant for Accuray Inc., Sunnyvale, CA, USA; however, this does not alter our adherence to all PLOS One policies on sharing data and materials.
