Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM
변준호, 권도훈, Lee Do-Heui, 박원형, 박중철, 안재성,
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변준호 ( Byun Joon-Ho )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
권도훈 ( Kwon Do-Hoon )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
( Lee Do-Heui )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
박원형 ( Park Won-Hyoung )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
박중철 ( Park Jung-Cheol )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
안재성 ( Ahn Jae-Sung )
University of Ulsan College of Medicine Asan Medical Center Department of Neurological Surgery
Abstract
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80-90% complete obliteration rate with a 2-3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30-40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.
키워드
Arteriovenous malformations; Radiosurgery; Complication
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