Clinical and radiological evaluation of long-term results of stereotactic proton beam radiosurgery in patients with cerebral arteriovenous malformations.

Within a period of nearly 10 years, from October, 1980, to May, 1990, a total of 68 patients with a cerebral arteriovenous malformation (AVM) were referred to a radiosurgical center in the United States for stereotactic Bragg peak proton beam therapy. Radiosurgery was chosen as an alternative treatment, either because the AVM was considered to be of high surgical risk due to its size and/or location, or because the patient refused surgery. In 63 patients (92.6%), complete clinical and radiological follow-up examinations were available. Clinical and radiological long-term results were correlated to size and to the Spetzler-Martin scale of the AVM. With increasing size or higher grade on the Spetzler-Martin scale, the clinical results of proton beam therapy became progressively worse. Of 37 patients with an AVM between 3 and 6 cm in diameter, only one-third showed amelioration of their clinical symptoms, and two-thirds remained the same or even deteriorated after radiation treatment. The same results apply to patients with very large AVM's, of whom only one-third profited from proton beam therapy. Although 85.7% of the patients in Spetzler-Martin Grades I and II showed postirradiation amelioration of their clinical symptoms, this compares to only 54.2% of the patients in Grade III, and only 24% in Grade IV. In regard to the radiological results of proton beam therapy, complete obliteration during long-term observation was only detectable in 10 patients or 15.9%, which is less than one-sixth of the whole group of 63 patients. All of these obliterated AVM's were smaller than 3 cm. Almost 85% of the patients treated using stereotactic proton beam therapy did not show any angiographic change in the radiological appearance of their AVM. The results reported here indicate that radiosurgery using stereotactic proton beam therapy is ineffective for the treatment of medium- or large-sized AVM's and should not be recommended for patients harboring an AVM larger than 3 cm. If proton beam treatment is contemplated, it should be restricted to AVM's that are less than 3 cm in size and whose location makes them easily accessible only for proton beam therapy.