Hypofractionated Stereotactic Radiosurgery For Brain Avm Post Aruba: Obliteration, Complication, And Hemorrhage Rates

Introduction: Patients harboring brain AVMs associated with moderate-high surgical morbidity (large lesions, deep location and eloquent cortex) are increasingly undergoing hypofractionated stereotactic radiosurgery (SRS) at our institution. Most published literature is based on a single fraction SRS technique. In this review we sought to evaluate/present our hypofractionated SRS experience using the Accuray Cyberknife device. Hypothesis: Cyberknife Stereotactic Radiosurgery (C-SRS) can be used for a high risk brain arteriovenous malformations (AVMs) with high rates of successful complete obliteration and low rates of hemorrhagic, death and major disability. Methods: We performed a retrospective analysis of all patients having undergone Cyberknife SRS for brain AVMs between 2013-2019 at a large community based tertiary care health system and identified 33 patients. Of these patients 12 had a minimum of 2 year follow-up. We divided the patients into hemorrhagic and non-hemorrhagic presentations, prior endovascular treatment with embolization and based on Spetzler Martin grades. Results: 58% males with median age of 44 and 9% presenting with hemorrhage. Median planning target volume (PTV) was 7.2 cc (range 1.25-15.56 cc) and median HFSRT dose was three fractions (range 3-5) of 10.25 Gy (range 8.5-11 Gy) each. Complete obliteration was achieved in 100% of patients after salvage SRS 21 Gy x1 fraction to a residual AVM volume in 2 patients. The median time to obliteration was 747 days. 3 of 12 patients suffered radiation necrosis1 patient with a large AVM (maximum diameter of 4 cm and PTV of 12.6 cc) suffered re-hemorrhage and radiation necrosis, but ultimately completely obliterated after 402 days and was left with mRS ≤2). Conclusion: Although we have a small sample size, fractionated SRS with Cyberknife resulted in 100% obliteration, low rates recurrent hemorrhage and low morbidity (no mortality). These outcomes are superior to published single fraction radiosurgery results in high risk patients. Further study with a prospective multicenter registry or as part of a larger RCT is warranted.