P03.06 Cavernous malformations of the brainstem: radiosurgical management with gamma knife

Abstract BACKGROUND About 20% of intracranial cavernous malformations (CM) occur in the brainstem. The greatest risk of brainstem CM is hemorrhage which can be devastating and even fatal in this location. The optimal management for these lesions would naturally be microsurgical resection. However, surgery in this location is associated with significant morbidity and mortality. Gamma knife radiosurgery provides a safer alternative. The purpose of this study is to investigate the efficacy of gamma knife radiosurgery for brainstem CM in preventing bleeding, as well as, assess safety with regards to radiation-induced complications. Additionally, we aimed to evaluate the feasibility and safety of volume-staged gamma knife radiosurgery for larger CM in the brainstem. MATERIAL AND METHODS Between September 2007 and August 2017, 48 patients with brainstem CM were treated by gamma knife. Thirty-two patients were available for follow up of at least one year. A total of 33 lesions were treated (one patient had two brainstem CM). Twenty-eight patients had at least one hemorrhagic event before radiosurgery. The patients underwent 40 gamma knife sessions. These included 28 single sessions (including two sessions for same patient for 2 different lesions in pons). Five patients had volume-staged gamma knife treatments due to the large size of the CM. The median total CM volume/lesion was 0.8 cc (0.1–30.4 cc), while the median target volume/session was 1 cc (0.1–11.5 cc). The median prescription dose was 12 Gy (10–14 Gy). RESULTS The mean follow up after treatment was 40 months (12–95 months). The annual hemorrhage rate (AHR) before gamma knife radiosurgery was 25.5%. After treatment there were a total of 5 hemorrhagic events with an overall AHR of 4.5%. Three hemorrhagic events occurred in the first 2 years after treatment with an AHR of 2.7% and 2 events more than 2 years after treatment with an AHR of 2.2%. No hemorrhagic events occurred among the patients treated by volume-staged radiosurgery. Clinical improvement was observed in 15 (46.9%) patients. Temporary adverse radiation events developed in 6 patients (19%). CONCLUSION Gamma knife radiosurgery provides an effective and safe treatment alternative to surgery for brainstem CM. Volume-staged gamma knife radiosurgery for brainstem CM appears to be a viable option for larger CM.

Download Full-text

Gamma Knife radiosurgery for cerebral cavernous malformation

Scientific Reports ◽

10.1038/s41598-019-56119-1 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 2

Author(s):

Cheng-Chia Lee ◽

Wei-Hsin Wang ◽

Huai-Che Yang ◽

Chung-Jung Lin ◽

Hsiu-Mei Wu ◽

...

Keyword(s):

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Annual Incidence ◽

Cavernous Malformations ◽

Alternative Treatment Option ◽

Median Volume ◽

Radiation Induced ◽

Risk Of Hemorrhage ◽

Median Margin

AbstractThis is a retrospective study examining the efficacy and safety of Gamma Knife radiosurgery (GKS) in treating patients with cerebral cavernous malformations (CCMs). Between 1993 and 2018, 261 patients with 331 symptomatic CCMs were treated by GKS. The median age was 39.9 years and females were predominant (54%). The median volume of CCMs was 3.1 mL. The median margin dose was 11.9 Gy treat to a median isodose level of 59%. Median clinical and imaging follow-up times were 69 and 61 months, respectively. After the initial hemorrhage that led to CCM diagnosis, 136 hemorrhages occurred in the period prior to GKS (annual incidence = 23.6%). After GKS, 15 symptomatic hemorrhages occurred within the first 2 years of follow-up (annual incidence = 3.22%), and 37 symptomatic hemorrhages occurred after the first 2 years of follow-up (annual incidence = 3.16%). Symptomatic radiation-induced complication was encountered in 8 patients (3.1%). Mortality related to GKS occurred in 1 patient (0.4%). In conclusion, GKS decreased the risk of hemorrhage in CCM patients presenting with symptomatic hemorrhage. GKS is a viable alternative treatment option for patients with surgically-inaccessible CCMs or significant medical comorbidities.

Download Full-text

P03.08 Large cerebral arteriovenous malformations management with Volume-staged gamma knife radiosurgery

Neuro-Oncology ◽

10.1093/neuonc/noz126.089 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii26-iii26

Author(s):

R M Emad Eldin ◽

W A Reda ◽

A M El-Shehaby ◽

K Abdel Karim ◽

A Nabeel ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Cerebral Arteriovenous Malformations ◽

Factors Affecting ◽

Prescription Dose ◽

The Mean ◽

Cerebral Avms ◽

Grade 3

Abstract BACKGROUND Large cerebral arteriovenous malformations (AVM) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged gamma knife radiosurgery (VSGR) has been developed for the treatment of large AVMs, to increase the efficacy and improve safety of treatment of these lesions. The aim of the study was to assess the efficacy and safety of VSGR technique for the treatment of large cerebral AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All cases had large AVMs (>10 cc). These were 29 patients. RESULTS Twenty-four patients completed radiographic follow up with 15 obliteration cases (62.5%). There was a total of 56 sessions performed. The mean AVM volume was 16 cc (10.1–29.3 cc). The mean prescription dose was 18 Gy (14–22 Gy). The mean follow up duration was 43 months (21–73 months). One patient died during follow up from unrelated cause. Two cases suffered haemorrhage during follow up. Symptomatic edema developed in 5 (17%) patients. The factors affecting obliteration were smaller total volume, higher dose/stage, non-deep location, compact AVM, AVM score less than 3, >18 Gy dose and <15 cc total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (p 0.012). T2 image changes were affected by SM grade 3 or more (p 0.013) and AVM score 3 or more (p 0.014). CONCLUSION VSGR provides an effective and safe treatment option for large cerebral AVMs. Smaller AVM volume is associated with higher obliteration rate.

Download Full-text

A planned combined stereotactic approach for cystic intracranial tumors

Journal of Neurosurgery ◽

10.3171/jns.2002.97.supplement_5.0610 ◽

2002 ◽

Vol 97 ◽

pp. 610-612 ◽

Cited By ~ 8

Author(s):

Wael Abdel Halim Reda ◽

Alla Abdel Hay ◽

Jeremy C. Ganz

Keyword(s):

Gamma Knife Radiosurgery ◽

Target Volume ◽

Cytotoxic Agents ◽

Content Type ◽

Cystic Component ◽

Prescription Dose ◽

Special Circumstances ◽

Mural Nodules ◽

Fine Print

✓ Cyst-associated tumors are classified as cysts with neoplastic mural nodules and intratumoral cysts. The solid component of many of these tumors may be appropriate for gamma knife radiosurgery (GKS). At present there is no systematic protocol for GKS treatment of patients harboring tumors with a cystic component. The purpose of this paper is to suggest such a program. Two cases are presented. One patient had a hemangioblastoma with a cyst and a mural nodule. The second patient had a craniopharyngioma with one large and two small intratumoral cysts. The course in both cases has been satisfactory in the short term. Although the 1-year follow-up period, however, does not provide a basis for determining the correct overall management of such tumors, the treatment strategy does illustrate a program for the management of tumors with associated cysts. Cysts with tumor nodules in their walls should first be treated with GKS followed by aspiration of the cyst contents, unless special circumstances make this unsuitable. This strategy enables treatment planning to take advantage of the natural barrier a cyst may place between a tumor and important surrounding structures. Intratumoral cysts may be aspirated and then treated with GKS, with every attempt made to cover the entire target volume including any residual cyst with the prescription dose. This form of treatment requires very careful follow up. It is probable that in some cases reaccumulation of cyst fluid may require the insertion of an Ommaya reservoir for repeated aspiration or the installation of cytotoxic agents such as bleomycin. This form of treatment is much less traumatic than surgery and does not hinder the performance of subsequent surgery, should this become necessary.

Download Full-text

Predictive Factors of Radiation-Induced Changes Following Single-Session Gamma Knife Radiosurgery for Arteriovenous Malformations

Journal of Clinical Medicine ◽

10.3390/jcm10102186 ◽

2021 ◽

Vol 10 (10) ◽

pp. 2186

Author(s):

Myung Ji Kim ◽

Kyung Won Chang ◽

So Hee Park ◽

Won Seok Chang ◽

Jong Hee Chang ◽

...

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Inverse Correlation ◽

Brain Parenchyma ◽

Magnetic Resonance Images ◽

Single Session ◽

Radiation Induced ◽

Induced Changes

We evaluated for possible predictors of radiation-induced changes (RICs) after gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs). We identified the nidal component within AVMs to analyze the correlation between the volume of brain parenchyma within the 50% isodose line (IDL) and RICs. We retrospectively reviewed patients with AVMs who underwent a single-session of GKRS at our institution between 2007 and 2017 with at least a 2-year minimum follow-up. Follow-up magnetic resonance images were evaluated for newly developed T2 signal changes and the proportions of nidus and intervening parenchyma were quantified. A total of 180 AVM patients (98 males and 82 females) with a median age of 34 years were included in the present study. The overall obliteration rate was 67.8%. The median target volume was 3.65 cc. The median nidus and parenchyma volumes within the 50% IDL were 1.54 cc and 2.41 cc, respectively. RICs were identified in 79 of the 180 patients (43.9%). AVMs associated with previous hemorrhages showed a significant inverse correlation with RICs. In a multivariate analysis, RICs were associated with a higher proportion of brain parenchyma within the 50% IDL (hazard ratio (HR) 169.033; p < 0.001) and inversely correlated with the proportion of nidus volume within the 50% IDL (HR 0.006; p < 0.001). Our study identified that a greater proportion of brain tissue between the nidus within the 50% IDL was significantly correlated with RICs. Nidus angioarchitectural complexity and the absence of a prior hemorrhage were also associated with RICs. The identification of possible predictors of RICs could facilitate radiosurgical planning and treatment decisions as well as the planning of appropriate follow-up after GKRS; this could minimize the risk of RICs, which would be particularly beneficial for the treatment of incidentally found asymptomatic AVMs.

Download Full-text

Brainstem cavernous malformations: the role of Gamma Knife surgery

Journal of Neurosurgery ◽

10.3171/2012.8.gks121066 ◽

2012 ◽

Vol 117 (Special_Suppl) ◽

pp. 164-169 ◽

Cited By ~ 13

Author(s):

Cheng-Chia Lee ◽

David Hung-Chi Pan ◽

Wen-Yuh Chung ◽

Kang-Du Liu ◽

Huai-Che Yang ◽

...

Keyword(s):

Gamma Knife ◽

Good Alternative ◽

Gamma Knife Surgery ◽

Neurological Deficits ◽

Cavernous Malformations ◽

Perifocal Edema ◽

Consciousness Disturbance ◽

Radiation Induced ◽

The Mean

Object The authors retrospectively reviewed the efficacy and safety of Gamma Knife surgery (GKS) in patients with brainstem cavernous malformations (CMs). The CMs had bled repeatedly and placed the patients at high risk with respect to surgical intervention. Methods Between 1993 and 2010, 49 patients with symptomatic CMs were treated by GKS. The mean age in these patients was 37.8 years, and the predominant sex was female (59.2%). All 49 patients experienced at least 2 instances of repeated bleeding before GKS; these hemorrhages caused neurological deficits including cranial nerve deficits, hemiparesis, hemisensory deficits, spasticity, chorea or athetosis, and consciousness disturbance. Results The mean size of the CMs at the time of GKS was 3.2 cm3 (range 0.1–14.6 cm3). The mean radiation dose directed to the lesion was 11 Gy with an isodose level at 60.0%. The mean clinical and imaging follow-up time was 40.6 months (range 1.0–150.7 months). Forty-five patients participated in regularly scheduled follow-up. Twenty-nine patients (59.2%) were followed up for > 2 years, and 16 (32.7%) were followed up for < 2 years. The pre-GKS annual hemorrhage rate was 31.3% (69 symptomatic hemorrhages during a total of 220.3 patient-years). After GKS, 3 episodes of symptomatic hemorrhage were observed within the first 2 years of follow-up (4.29% annual hemorrhage rate), and 3 episodes of symptomatic hemorrhage were observed after the first 2 years of follow-up (3.64% annual hemorrhage rate). In this study of 49 patients, symptomatic radiation-induced complications developed in only 2 patients (4.1%; cyst formation in 1 patient and perifocal edema with neurological deficits in the other patient). There were no deaths in this group. Conclusions Gamma Knife surgery is effective in reducing the rate of recurrent hemorrhage. In the authors' experience, it was possible to control bleeding using a low-dose treatment. In addition, there were few symptomatic radiation-induced complications. As a result, the authors believe that GKS is a good alternative treatment for brainstem CMs.

Download Full-text

RTHP-11. THE EFFECT OF PRESCRIPTION ISODOSE LINE ON LOCAL CONTROL AND RADIOGRAPHIC RESPONSE IN GAMMA KNIFE RADIOSURGERY OF VESTIBULAR SCHWANNOMA

Neuro-Oncology ◽

10.1093/neuonc/noz175.884 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi212-vi212

Author(s):

Achiraya Teyateeti ◽

Christopher Graffeo ◽

Avital Perry ◽

Paul Brown ◽

Bruce Pollock ◽

...

Keyword(s):

Gamma Knife ◽

Local Control ◽

Tumor Volume ◽

Gamma Knife Radiosurgery ◽

Hearing Preservation ◽

History Of ◽

Prescription Dose ◽

Preservation Rate ◽

Prescription Isodose

Abstract Traditionally, the 50% isodose line (IDL) is used for prescription dose when vestibular schwannomas (VS) are treated with Gamma Knife radiosurgery (GKRS). To compare the effect of IDL on treatment outcomes, propensity score-matched analysis according to age at time of GKRS and tumor volume (TV) between cohorts treated at 40%IDL and 50%IDL was performed. Patients with no history of neurofibromatosis, GKRS prescribed marginal dose of 12–14 Gy and TV ≤ 10 cc were identified. Patients were excluded if follow-up time was < 2 years. Eventually, 30 and 28 patients were included in 40%IDL and 50%IDL cohorts, respectively. Mean age and TV were not significantly different between 40%IDL and 50%IDL groups; 54.5 versus 54.0 years (p=0.891) and 2148.61 versus 2031.10 mm3 (p=0.844), respectively. Median prescription dose was 12 Gy in both groups. At median follow-up times of 111 and 72 months, the 2, 5 and 10-year local control were 100%, 96.4% and 96.4% for 40%IDL and 96.4%, 86.7%, and 86.7% for 50%IDL (p=0.243), respectively. Among 40 patients with accessible follow-up MRIs (40%IDL-n=19, 50%IDL-n=21), volume reduction at last follow-up MRIs and rate of reduction per year for 40%IDL and 50%IDL were 48.1% versus 38.3% (p=0.05) and 5.5% versus 6% (p=0.749), respectively. Of 21 patients with serviceable hearing prior to GKRS and available audiograms after GKRS (40%IDL-n=8, 50%IDL-n=13), the 2, 5 and 10-year hearing preservation rate were 100%, 83.3% and 62.5% for 40%IDL versus 76.2%, 57.1% and 11.4% for 50%IDL (p=0.017). Facial paresthesia, facial palsy and ataxia/gait disturbance requiring steroid and/or shunt were lower in 40%IDL compared to the 50%IDL; 6.7% versus 17.9% (p=0.208) and 3.3% versus 7.1% (p=0.532). To summarize, VS treated at 40%IDL have slightly better local control, although not statistically significant, compared to tumors treated at 50%IDL. However, hearing preservation and safety seem to be more favorable toward 40%IDL group.

Download Full-text

GAMMA KNIFE RADIOSURGERY–INDUCED CAVERNOUS HEMANGIOMA

Neurosurgery ◽

10.1227/01.neu.0000344005.23146.cc ◽

2009 ◽

Vol 64 (5) ◽

pp. E1006-E1007 ◽

Cited By ~ 18

Author(s):

Yasuo Sasagawa ◽

Takuya Akai ◽

Shoutarou Itou ◽

Hideaki Iizuka

Keyword(s):

Magnetic Resonance ◽

Gamma Knife ◽

Cavernous Hemangioma ◽

Rare Case ◽

Gamma Knife Radiosurgery ◽

Magnetic Resonance Images ◽

Weighted Image ◽

Resected Tumor ◽

Radiation Induced

Abstract OBJECTIVE We report a rare case of gamma knife radiation–induced cavernous hemangioma. CLINICAL PRESENTATION A 35-year-old man underwent resection of a left vestibular schwannoma and gamma knife radiosurgery (maximal dose, 24 Gy; marginal dose, 12 Gy) for the residual schwannoma. Follow-up magnetic resonance images showed no tumor progression. Ten years later, he developed right hemihyperesthesia and mild hemiparesis. Magnetic resonance imaging revealed a size reduction at the resected tumor site and a newly developed lesion in the adjacent pons. No connection was observed between the new mass and the previous tumor. The T2-weighted image showed the new mass as heterogeneous and “popcorn-like” with a mixed signal intensity core and a hypointense hemosiderin rim. Two years after its appearance, the new lesion appeared hypointense on the T2-weighted image, with a hyperintense core on the T1-weighted image. These findings were compatible with cavernous hemangioma. INTERVENTION We diagnosed the new lesion as a radiation-induced cavernous hemangioma. Ten days after admission, symptoms improved without surgical intervention. CONCLUSION Gamma knife radiosurgery induced this rare case of cavernous hemangioma in an area that received a low dose of irradiation and was distant from the primary tumor. Because patients undergoing radiosurgery face the possibility, although small, that such neoplasms may occur, they should be followed for many years.

Download Full-text

Gamma Knife radiosurgery for the treatment of intracranial dural arteriovenous fistulas

Interventional Neuroradiology ◽

10.1177/1591019916683689 ◽

2016 ◽

Vol 23 (2) ◽

pp. 211-220 ◽

Cited By ~ 7

Author(s):

Adam A Dmytriw ◽

Michael L Schwartz ◽

Michael D Cusimano ◽

Vitor Mendes Pereira ◽

Timo Krings ◽

...

Keyword(s):

Gamma Knife ◽

De Novo ◽

Gamma Knife Radiosurgery ◽

Target Volume ◽

Endovascular Embolization ◽

Arteriovenous Fistulas ◽

Alternative Treatment Option ◽

Target Volumes ◽

One Year ◽

Symptom Palliation

Background Intracranial dural arteriovenous fistulae (DAVF) may present a treatment challenge. Endovascular embolization is in most cases the first line of treatment but does not always achieve cure. Gamma Knife (GK) radiosurgery represents an alternative treatment option, and the purpose of this study was to further evaluate its utility. Methods We reviewed all cases of DAVF treated between 2009 and 2016 at our institution with GK radiosurgery independently, or following failed/refused endovascular or surgical management. Patients’ clinical files, radiological images, catheter angiograms, and surgical DAVF disconnection reports were retrospectively reviewed. Results Sixteen DAVF (14 patients) treated by GK radiosurgery were identified. Eleven fistulae were aggressive and five were benign. Marginal doses ranged from 15 to 25 Gy. Target volumes ranged from 0.04 to 4.47 cm3. In all symptomatic patients, GK treatment resulted in symptom palliation. In 13/15 lesions, cure of symptoms (86.0%) was reported. One lesion was asymptomatic. Angiographic cure was achieved in eight cases (50%), small residual DAVF occurred in four, and four were unchanged. One patient developed headache that resolved at one year. No hemorrhage occurred during the follow-up period. There was no significant association between Borden type and cure rate. Prior failed endovascular treatment and small target volume were associated with lower rates of cure. Conclusions Stereotactic radiosurgery is viable treatment for DAVF. It is very effective in palliating symptoms as a de novo approach or adjunctive to endovascular therapy. In our experience it is only somewhat effective in achieving complete angiographic cure.

Download Full-text

Gamma knife radiosurgery for pilocytic astrocytomas

Journal of Neurosurgery ◽

10.3171/jns.2002.97.supplement_5.0677 ◽

2002 ◽

Vol 97 ◽

pp. 677-680 ◽

Cited By ~ 45

Author(s):

Jörgen Boëthius ◽

Elvar Ulfarsson ◽

Tiit Ráhn ◽

Bodo Lippitz

Keyword(s):

Side Effects ◽

Gamma Knife ◽

Gamma Knife Radiosurgery ◽

Content Type ◽

Natural Time ◽

Pilocytic Astrocytomas ◽

Follow Up Studies ◽

Prescription Dose ◽

Fine Print

Object. The authors report on the follow-up studies in patients treated at the Karolinska Hospital to evaluate the efficacy of gamma knife radiosurgery (GKS) for pilocytic astrocytoma. Methods. Twelve male and seven female patients were treated (mean age 10.6 years [range 2–60 years]). Sixteen of these patients were children in whom GKS was performed to treat residual tumor after surgery. Most tumors were treated with a prescription dose of 10 to 12 Gy (range 9–20 Gy). The corresponding maximum dose varied between 22 and 30 Gy (range 10–50 Gy). The median clinical follow-up time was 7 years and mean clinical follow-up time 8.5 years. Median radiological follow-up time was 4.7 years and the mean radiological follow-up time was 5.9 years. Tumor control was achieved in all patients. In 85% of the cases a moderate tumor volume reduction was observed after GKS. This result occurred despite the low prescription dose administered. The radiological follow-up studies showed adverse radiation effects in 25% of patients with increasing contrast enhancement and some edema. These effects generally appeared within 7 months and resolved later. Cyst development occurred in two patients, which may have been treatment related. Conclusions. It appears that small pilocytic astrocytomas may be treated with low-prescription-dose GKS, resulting in satisfactory clinical outcomes and only minor side effects. There were a certain number of radiologically demonstrated side effects that appeared relatively early but subsequently resolved. This study should be regarded as a preliminary one because the number of patients is small and the follow-up period is short compared with the natural time course of the disease.

Download Full-text

Low Dose Gamma-knife Radiosurgery for Diffuse Brainstem Gliomas

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v25i3.1125 ◽

2018 ◽

Vol 25 (3) ◽

pp. 217-225

Author(s):

Julio C. Antico ◽

Daniel Benzecry Almeida

Keyword(s):

Effective Treatment ◽

Gamma Knife ◽

Tumor Size ◽

Radiation Effects ◽

Gamma Knife Radiosurgery ◽

Prescription Dose ◽

Brainstem Tumors ◽

The Mean ◽

Early Late

Introduction: Diffuse brainstem glial tumors remain a challenge. Despite many advances in neurosurgical techniques, no effective treatment is currently available. Recently, some authors showed beneficial results with gamma-knife radiosurgery (GK) for focal brainstem tumors. Objective: to analyze safety and effectiveness of GK in patients with diffuse brainstem gliomas. Methods: Eleven patients with diffuse brainstem gliomas treated with Gamma-knife from November 2001 to June 2009 were included. Complete data such as age, gender, symptoms, tumor size, prescription dose, adverse radiation effects and an early late follow-up were analyzed. Results: The mean age was 28.7 years (ranging from 1y 7m to 62y). Six patients were female and 5 were male. The gamma-knife prescription dose ranged from 6 to 7 Gy. All patients had clinical and imaging improvement at an early follow-up, although in 6, there was a late increase in tumor size and death. The others remained clinically stable or better. Larger tumors had a direct relationship with a poorer prognosis. No patient developed complications related to the radiosurgical treatment. Conclusion: Gamma-Knife is a safe and effective treatment for selected patients with diffuse brainstem tumors. The authors propose lower doses. Further studies are mandatory in order to analyze which patients could benefit from this treatment.

Download Full-text