Tesis

Hubungan Karakteristik Radiologis dengan Luaran Obliterasi Pasien Arteriovenous Malformation Serebral yang Diterapi dengan Gamma Knife Radiosurgery = Association of Radiological Features with Obliteration Outcome In Patients with Cerebral Arteriovenous Malformation Treated with Gamma Knife Radiosurgery.

Pendahuluan: Arteriovenous malformation (AVM) merupakan kelainan vaskular kongenital yang berisiko tinggi menimbulkan perdarahan intrakranial. Gamma Knife Radiosurgery (GKRS) menjadi salah satu terapi non-invasif yang bertujuan mengobliterasi nidus secara bertahap. Meskipun tingkat obliterasi telah banyak diteliti, kecepatan obliterasi—sebagai parameter penting dalam menilai efektivitas GKRS—masih jarang menjadi fokus penelitian, terutama di Indonesia. Penilaian karakteristik radiologis yang terukur, seperti ukuran nidus, jumlah feeding artery dan draining vein, dapat memberikan wawasan terhadap faktor-faktor yang mempengaruhi kecepatan obliterasi. Tujuan: Penelitian ini bertujuan mengevaluasi hubungan antara karakteristik radiologis dan kecepatan obliterasi AVM pasca-GKRS, dan menentukan faktor-faktor yang berkontribusi pada peningkatan kecepatan obliterasi pada pasien AVM paska GKRS, guna memperkuat basis ilmiah pengambilan keputusan klinis untuk pasien dengan AVM. Metode: Penelitian ini menggunakan pendekatan kohort retrospektif kohort-analitik selama bulan Agustus 2018 hingga Desember 2024. Dilakukan pengambilan sampel pada pasien AVM paska terapi GKRS yang memiliki data radiologis lengkap. Kemudian dilakukan analisa pada 13 variabel independen terhadap kecepatan obliterasi. Hasil: Sebanyak 33 pasien AVM serebral yang menjalani Gamma Knife Radiosurgery (GKRS) dianalisis. Kejadian radiation-induced change (RIC) ditemukan pada 63,6% pasien dan terbukti memiliki hubungan yang bermakna secara statistik terhadap tingkat obliterasi akhir (p = 0,033) serta kecepatan obliterasi (p < 0,001). Analisis Kaplan-Meier menunjukkan laju obliterasi yang lebih cepat dan tinggi pada kelompok RIC dibanding non-RIC (log-rank, p < 0,05). Model regresi multivariat dan pathway analysis menunjukkan bahwa RIC berkontribusi langsung dan tidak langsung terhadap pencapaian obliterasi, menjadikannya indikator potensial terhadap efektivitas radiosurgery pada AVM. Kesimpulan: Kecepatan obliterasi merupakan suatu karakteristik hasil numerisasi pemeriksaan yang dapat menggambarkan hasil terapi pasien AVM paska GKRS dimana faktorfaktor yang berkontribusi terhadap kecepatan obliterasi mencakup nilai SM grade, ukuran AVM berdasarkan SM grade, VRAS, ukuran AVM berdasarkan VRAS, durasi treatment, jumlah tembakan GKRS, kejadian RIC dan faktor kontributor yang paling pe3nting yakni volume AVM pre-tindakan GKRS. Diperlukan penelitian lebih lanjut dalam bentuk cohort prospektif untuk menganalisis variabel lain yang sekiranya berkontribusi untuk kecepatan obliterasi dan faktor-faktor yang mempengaruhi volume AVM termasuk penelitian lebih lanjut yang mendalami angiomorfologi AVM dan hubungannya dengan treatment GKRS.


Introduction: Arteriovenous malformation (AVM) is a congenital vascular anomaly with a high risk of causing intracranial hemorrhage. Gamma Knife Radiosurgery (GKRS) is a noninvasive treatment modality aimed at gradually obliterating the nidus. While obliteration rates have been extensively studied, the rate of obliteration—an important parameter for assessing GKRS efficacy—remains underexplored, particularly in Indonesia. Quantitative assessment of radiologic characteristics such as nidus size, number of feeding arteries, and draining veins may provide valuable insights into factors influencing the obliteration rate. Objective: This study aims to evaluate the relationship between radiologic characteristics and the obliteration rate of AVMs following GKRS, and to identify contributing factors associated with faster obliteration. The findings are expected to strengthen the scientific basis for clinical decision-making in the management of patients with cerebral AVMs. Methods: This study employed a retrospective analytic cohort design, conducted from August 2018 to December 2024. Patients with cerebral AVMs who underwent GKRS and had complete radiologic data were included. Thirteen independent variables were analyzed to assess their association with the rate of obliteration. Standardized protocols were utilized for data collection, and all relevant variables were systematically evaluated throughout the study period. Results: A total of 33 cerebral AVM patients who underwent Gamma Knife Radiosurgery (GKRS) were analyzed. Radiation-induced changes (RIC) were observed in 63.6% of patients and showed a statistically significant association with both final obliteration rate (p = 0.033) and obliteration velocity (p < 0.001). Kaplan-Meier analysis demonstrated a significantly faster and higher obliteration rate in the RIC group compared to the non-RIC group (log-rank, p < 0.05). Multivariate regression and pathway analysis revealed that RIC contributed both directly and indirectly to AVM obliteration, supporting its role as a potential predictive marker of radiosurgical response in cerebral AVMs. Conclusions: The obliteration rate is a quantifiable radiologic outcome that reflects the therapeutic response in AVM patients following GKRS. Factors contributing to the obliteration rate include SM grade, AVM size based on SM grade, VRAS, AVM size based on VRAS, treatment duration, number of GKRS shots, the occurrence of radiation-induced changes (RIC), with the most significant contributing factor being the pre-treatment AVM volume. Further prospective cohort studies are warranted to explore additional variables that may influence the obliteration rate, as well as to investigate factors affecting AVM volume, including studies focusing on AVM angiomorphology and its relationship to GKRS outcomes