Elsevier

World Neurosurgery

Volume 84, Issue 3, September 2015, Pages 795-804
World Neurosurgery

Original Article
Radiosurgery for Cerebral Arteriovenous Malformations in Elderly Patients: Effect of Advanced Age on Outcomes After Intervention

https://doi.org/10.1016/j.wneu.2015.05.012Get rights and content

Objective

Cerebral arteriovenous malformations (AVM) are infrequently diagnosed and treated in elderly patients (age, >60 years). We hypothesize that, in contrast to AVM surgical outcomes, radiosurgery outcomes are not adversely affected by increased age. The goals of this case-control study are to analyze the radiosurgery outcomes for elderly patients with AVMs and determine the effect of elderly age on AVM radiosurgery outcomes.

Methods

We evaluated a prospective database of patients with AVMs treated with radiosurgery from 1989 to 2013. Elderly patients with AVM (age, ≥60 years) with radiologic follow-up of ≥2 years or nidus obliteration were selected for analysis, and matched, in a 1:1 fashion and blinded to outcome, to adult nonelderly patients with AVM (age, <60 years). Statistical analyses were performed to determine actuarial obliteration rates and evaluate the relationship between elderly age and AVM radiosurgery outcomes.

Results

The matching processes yielded 66 patients in each of the elderly and nonelderly AVM cohorts. In the elderly AVM cohort, the actuarial AVM obliteration rates at 3, 5, and 10 years were 37%, 65%, and 77%, respectively; the rates of radiologically evident, symptomatic, and permanent radiation-induced changes were 36%, 11%, and 0%, respectively; the annual hemorrhage risk after radiosurgery was 1.1%, and the AVM-related mortality rate was 1.5%. Elderly age was not significantly associated with AVM obliteration, radiation-induced changes, or hemorrhage after radiosurgery.

Conclusions

Advanced age does not appear to confer appreciably worse AVM radiosurgery outcomes, unlike its negative effect on AVM surgical outcomes. Thus, when an AVM warrants treatment, radiosurgery may be the preferred treatment for elderly patients.

Introduction

Most cerebral arteriovenous malformations (AVMs) are diagnosed and treated by the third or fourth decades of life 1, 2, 11. Therefore, diagnosis and treatment of an AVM in elderly patients (age, ≥60 years) is relatively uncommon, although increases in life expectancy over time may result in more frequent AVM diagnoses in the elderly population. A recent meta-analysis of risk factors for AVM hemorrhage found increasing age to be an independent predictor of hemorrhage risk (29). Given the poorer neurological reserve in elderly patients compared with their younger counterparts, stroke secondary to AVM rupture may be particularly devastating in this vulnerable patient population (23).

AVM surgical outcomes have been previously shown to be poorer in elderly patients 9, 28, 30. A similar inverse correlation between favorable outcome and age has been described for AVM radiosurgery 40, 52. However, the negative effect of age on post-treatment outcomes in patients with AVM when treated by radiosurgery has not been consistently observed in prior analyses 6, 10, 12, 13, 14, 16, 17, 18, 20, 25, 26, 27, 33, 36, 41, 53. Furthermore, a study evaluating the radiosurgery outcomes in elderly patients with AVM has not been performed. Therefore, we hypothesize that, unlike surgical outcomes, increased patient age does not significantly worsen AVM radiosurgery outcomes. In this retrospective case-control study, our aims are to 1) analyze the outcomes after the treatment of elderly patients with AVM by radiosurgery, 2) define the predictors of obliteration and radiosurgery-induced complications after radiosurgery for AVMs in elderly patients, and 3) determine the effect of elderly age on AVM radiosurgery outcomes.

Section snippets

Patient Selection

We retrospectively evaluated a prospective, institutional review board-approved, database of approximately 1400 patients with AVM who were treated with gamma knife radiosurgery at the University of Virginia from 1989 to 2013. The inclusion criteria for the case (elderly) cohort were 1) patient age 60 years or more, 2) sufficient data regarding baseline patient characteristics, AVM features, and outcomes after radiosurgery, and 3) minimum of 2 years of radiologic follow-up after radiosurgery,

Comparison of Baseline Data for Elderly and Nonelderly AVM Cohorts

The overall study population was comprised of 132 patients with AVM, evenly divided between 66 patients in each of the elderly and nonelderly AVM cohorts. Table 1 details the comparison of the patient, AVM, and radiosurgery variables between the 2 cohorts. As expected, patients in the elderly AVM cohort had significantly older (67.0 ± 5.4 vs. 36.1 ± 11.6 years; P < 0.0001) and had, given the age component in its calculation, significantly higher RBAS (1.70 ± 0.31 vs. 1.11 ± 0.30; P < 0.0001).

Discussion

The management of AVMs should include the consideration of patient, AVM, and treatment factors. The risks of intervention must be weighed against an AVM's natural history, which has been shown to vary considerably based on the angioarchitecture of the nidus (46). Given the correlation of increasing age with both AVM hemorrhage risk and procedural morbidity, a significant dilemma arises regarding the appropriate management of AVMs in elderly patients 5, 30, 40. In a study of 240 patients with

Conclusions

AVM radiosurgery can be performed in elderly patients (age, >60 years) with a favorable risk-to-benefit profile. When feasible, a margin dose of at least 22 Gy should be delivered to optimize radiosurgical efficacy. The incidence of symptomatic complications after radiosurgery was modest, the majority of which were only associated with transient clinical manifestation. In addition, the risk of latency period hemorrhage was very low. Advanced age does not appear to adversely impact radiosurgery

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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