Gamma Knife Radiosurgery of Brain Cavernomas
Purpose: Radiosurgery of cavernomas should prevent rebleeding, growth of the lesion, and deterioration of clinical symptoms. However, there is no direct diagnostic tool to verify the endpoints of treatment. At present, the positive effects of radiosurgery
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Abstract Purpose: Radiosurgery of cavernomas should prevent rebleeding, growth of the lesion, and deterioration of clinical symptoms. However, there is no direct diagnostic tool to verify the endpoints of treatment. At present, the positive effects of radiosurgery are identified by clinical observation and analysis of imaging changes on magnetic resonance imaging during a sufficiently long follow-up period. Methods: Between 1992 and 2000, a total of 112 patients with brain cavernomas were treated with Gamma Knife radiosurgery at our center. In all, 59 patients experienced bleeding before radiosurgery; the remainder did not. The median age of patients was 42 years, the median volume of the cavernomas was 0.9 cm3, and the median applied marginal dose was 16 Gy. Results: After a 2-year latent interval after treatment (median follow-up 84 months), the risk of bleeding in the group of patients with bleeding before radiosurgery had decreased from 3.7 % to 0.2 %. For the patients without bleeding before radiosurgery, the annual risk of bleeding was 0.8 %. The cavernoma size decreased in 53.0 % of cases and increased in 6.4 %. Epilepsy, if present before the treatment, was alleviated in 45 % of cases. The risks of temporary or permanent morbidity caused by radiosurgery were 14.6 % and 0.9 %, respectively. Conclusion: Radiosurgery of cavernomas was associated with a low risk of permanent morbidity. The risk of rebleeding after the 2-year latent interval after radiosurgery had decreased. Treatment of cavernomas with no history of bleeding was halted at our center.
Introduction
Keywords Bleeding • Cavernoma • Gamma Knife radiosurgery • Results
Material and Methods
R. Liscak (), D. Urgosik, G. Simonova, J. Vymazal, and J. Semnicka Hospital Na Homolce, Roentgenova 2, Prague 150 30, Czech Republic e-mail: [email protected]
The goal of Gamma Knife radiosurgery (GKS) of brain cavernomas is mainly to prevent the risk of rebleeding after the treatment. An arteriovenous malformation (AVM) visible on angiography is treated through proliferative and degenerative changes of tiny vessels inside the capillary nidus, leading to their obliteration [16]. Feeding arteries with larger diameters and sometimes even monstrous draining varicose veins are passively obliterated thereafter by formation of thrombus when blood flow is halted through the nidus. The cure can be verified by angiography, showing that the AVM has disappeared after its obliteration. Both these aspects are missed by treating cavernomas with radiosurgery. Cavernomas are often formed by larger lacunas with no capillary nidus, and there is no diagnostic tool to verify the successful endpoint of the treatment because cavernomas are angiographically occult. However, it is possible to hypothesize that focused irradiation hits the angiographically occult feeders around the cavernoma, depriving the lesion from its sustenance. Indeed, the regression and decrease of a cavernoma is frequently observed after radiosurgery, although the pathophysiological process behind these c
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