Gamma Knife Radiosurgery of the Brain Stem Cavernomas

Over 6 years (1992 - 1998) 26 patients with brain stem cavernomas were treated using the Leksell gamma knife in Prague. 25 patients had a follow up of 6 - 66, median 24 months. Annual risk of bleeding before radiosurgery was 4 %. After gamma knife treatment sudden impairment of neurodeficit reported as rebleeding was observed in 4 patients at 6 - 51 months, median 16.5 months, after radiosurgery. This represented a 6.8 % risk of rebleeding after radiosurgery, which is not significantly different from the risk before radiosurgery. MRI or CT was performed in 24 patients 6 - 48, median 24, months after radiosurgery. There were no signs of rebleeding in any of the patients, nor any increase of the cavernoma. A decrease of cavernoma size was observed in 8 (33 %) of patients. Temporary collateral edema after radiosurgery was detected in 5 (21 %) of patients 3 - 12, median 11, months after radiosurgery. Neurodeficit was observed in 21 of 26 patients before radiosurgery. Improvement of the neurodeficit was detected in 9 (43 %) of them 6 - 36, median 8, months after radiosurgery. Temporary morbidity caused by collateral edema or rebleeding occurred in 7 patients (28 %) and permanent morbidity remained in 2 patients (8 %). 2 patients died because of rebleeding 6 and 51 months after radiosurgery and the third patient for unrelated reason. Radiosurgery of the brain stem cavernomas was indicated when there was bleeding in the history or progressive neurodeficit and microsurgery was considered too risky. Leksell gamma knife radiosurgery of cavernomas has proved its low morbidity and zero mortality. In case of an insufficient effect of radiosurgery, or if the protective effect from rebleeding comes too late, morbidity and mortality can correspond to the natural course of the disease, as it was left without any treatment.

Key words:

Cavernoma - Angiographically Occult Vascular Malformation - Radiosurgery - Therapy - Result

References

• 1 Aiba T, Tanaka R, Koike T, Kameyama S, Takeda N, Komata T. Natural history of intracranial cavernous malformations.  J Neurosurg. 1995;  83 56-59
• 2 Amin-Hanjani S, Ogilvy C S, Candia G J, Lyons S, Chapman P H. Stereotactic radiosurgery for cavernous malformations: Kjellberg's experience with proton beam therapy in 98 cases at the Harvard cyclotron.  Neurosurgery. 1998;  42 1229-1238
• 3 Amin-Hanjani S, Ogilvy C S, Ojemann R G, Crowell R M. Risks of surgical management for cavernous malformations of the nervous system.  Neurosurgery. 1998;  42 1220-1228
• 4 Bednář B. Patologie I - Obecná patologie. Praha: Avicenum 1982: 321
• 5 Bitzer M, Opitz H, Popp J. et al . Angiogenesis and brain oedema in intracranial meningiomas: influence of vascular endothelial growth factor.  Acta Neurochir (Wien). 1998;  140 333-340
• 6 Cedzich C, Pechstein U, Zentner J, Van Roost D. Minimally invasive stereotactically-guided extirpation of brain stem cavernoma with the aid of electrophysiological methods.  Minim Invas Neurosurg. 1999;  42 41-43
• 7 Colombo F, Pozza F, Chierego G, Casentini L, De Luca G, Francescon P. Linear accelerator radiosurgery of cerebral arteriovenous malformations: an update.  Neurosurgery. 1994;  34 14-21
• 8 Curling O, Kelly D L, Elster A D, Craven T E. An analysis of the natural history of cavernous angiomas.  J Neurosurg. 1991;  75 702-708
• 9 Duffau H, Capelle L, Sichez J P. et al . Early radiologically proven rebleeding from intracranial cavernous angiomas: report of 6 cases and review of the literature.  Acta Neurochirurgica (Wien). 1997;  139 914-922
• 10 Friedman W A, Bova F J, Mendenhall W M. Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome.  J Neurosurg. 1995;  82 180-189
• 11 Fritschi J A, Reulen H J, Spetzler R F, Zabramski J M. Cavernous malformations of the brain system.  Acta Neurochirurgica (Wien). 1994;  130 35-46
• 12 Gewirtz R J, Steinberg G K, Crowley R, Levy R P. Pathological changes in surgically resected angiographically occult vascular malformations after radiation.  Neurosurgery. 1998;  42 738-743
• 13 Goldman C K, Bharara S, Palmer C A. et al . Brain edema in meningiomas is associated with increased vascular endothelial growth factor expression.  Neurosurgery. 1997;  40 1269-1277
• 14 Gomori J M, Grossman R I, Goldberg H I, Hackney D B, Zimmerman R A, Bilaniuk L T. Occult cerebral vascular malformations: high-field MR imaging.  Radiology. 1986;  158 707-713
• 15 Hsu F PK, Rigamonti D, Huhn S L. Epidemiology of cavernous malformations. In: Awad IA, Barrow DL eds. Cavernous malformations Illinois: AANS 1993: 13-23
• 16 Chang S D, Levy R P, Adler J R, Martin D P, Krakovitz P R, Steinberg G K. Stereotactic radiosurgery of angiographically occult vascular malformations: 14-years experience.  Neurosurgery. 1998;  43 213-221
• 17 Joanes V, Cerdá-Nicolas M, Ciudad J, Barcia-Salorio J L. Experimental arterial lesions after narrow-beam gamma irradiation used in stereotactic radiosurgery.  Acta Neurochirurgica (Wien). 1998;  140 1077-1081
• 18 Kalkanis S N, Caroll R S, Zhang J, Zamani A A, Black Pmc L. Correlation of vascular endothelial growth factor messenger RNA expression with peritumoural vasogenic cerebral edema in meningiomas.  J Neurosurg. 1996;  85 1095-1101
• 19 Karlsonn B, Kihlstrom L, Lindquist C, Ericson K, Steiner L. Radiosurgery for cavernous malformations.  J Neurosurg. 1998;  88 293-297
• 20 Kashiwagi S, Loveren H R, Tew Jr J M. et al . Diagnosis and treatment of vascular brain-stem malformations.  J Neurosurg. 1990;  72 27-34
• 21 Kida Y, Kobayashi T, Tanaka T. Radiosurgery of symptomatic angiographically occult vascular malformations with gamma knife. In: Kondziolka D, ed. Radiosurgery, 1995 Basel: Karger 1996 1: 207-217
• 22 Kondziolka D, Lunsford L D, Coffey R J, Bissonette D J, Flickinger J C. Stereotactic radiosurgery of angiographically occult vascular malformations: indications and preliminary experience.  Neurosurgery. 1990;  27 892-900
• 23 Kondziolka D, Lunsford L D, Flickinger J C, Kestle J RW. Reduction of hemorrhage risk after stereotactic radiosurgery for cavernous malformations.  J Neurosurg. 1995;  83 825-831
• 24 Kondziolka D, Lunsford L D, Kestle J RW. The natural history of cerebral cavernous malformations.  J Neurosurg. 1995;  83 820-824
• 25 Lawton M T, Jacobowitz R, Spetzler R F. Redefined role of angiogenesis in the pathogenesis of dural arteriovenous malformations.  J Neurosurg. 1997;  87 267-274
• 26 Ligon B L. The mystery of angiography and the “unawarded” Nobel prize: Egas Moniz and Hans Christian Jacobaeus.  Neurosurgery. 1998;  43 602-611
• 27 Liščák R, Vladyka V, Šimonová G, Vymazal J, Janoušková L. Leksell gamma knife radiosurgery of the tumor glomus jugulare and tympanicum, Stereotactic and Funct.  Neurosurg. 1998;  70 (suppl 1) 152-160
• 28 Liščák R, Vladyka V, Šimonová G, Novotný J. Gamma knife radiosurgery of meningiomas - preliminary results and complications.  J Radiosurg. 1998;  1 35-42
• 29 Liščák R, Vladyka V, Šimonová G, Šubrt O. Radiochirurgická léčba angiograficky okultních vaskulárních malformací (AOVM).  Čes a Slov Neurol Neurochir. 1996;  59/92 269-275
• 30 Marin-Padilla M. Vascular malformation of the cerebral nervous system. Embryological considerations. In: Yasargil MG. AVM of the brain, history, embryology, pathological considerations, hemodynamics, diagnostic studies, microsurgical anatomy Stuttgart: Georg Thieme Verlag 1987: 45-47
• 31 Michelson W J. Conservative management. In: Awad IA, Barrow DL eds. Cavernous malformations Illinois: AANS 1993: 81-85
• 32 Pollock B, Lunsford L D, Kondziolka D, Maitz A, Flickinger J C. Patient outcomes after stereotactic radiosurgery for “operable” arteriovenous malformations.  Neurosurgery. 1994;  35 1-8
• 33 Porter R W, Detwiler P W, Spetzler R F. et al . Cavernous malformations of the brainstem: experience with 100 patients.  J Neurosurg. 1999;  90 50-58
• 34 Pozzati E, Acciarri N, Tognetti F, Marliani F, Giangaspero F. Growth, subsequent bleeding, and de novo appearance of cerebral cavernous angiomas.  Neurosurgery. 1966;  38 662-670
• 35 Robinson J R, Awad I A. Clinical spectrum and natural course. In: Awad IA, Barrow DL eds. Cavernous malformations Illinois: AANS 1993: 25-36
• 36 Robinson J R, Awad I A, Magdinec M, Paranandi L. Factors predisposing to clinical disability in patients with cavernous malformations of the brain.  Neurosurgery. 1993;  32 730-736
• 37 Robinson J R, Awad I A, Masaryk T J, Estes M L. Pathological heterogeneity of angiographically occult vascular malformations of the brain.  Neurosurgery. 1993;  33 547-555
• 38 Rothbart D, Awad I A, Lee J, Kim J, Harbaugh R, Criscuolo G R. Expression of angiogenic factors and structural proteins in central nervous system vascular malformations.  Neurosurgery. 1996;  38 915-925
• 39 Scott R M, Barnes P, Kupsky W, Adelman L S. Cavernous angiomas of the central nervous system in children.  J Neurosurge. 1992;  76 3846
• 40 Seo Y, Fukuoka S, Takanashi M, Nakagawara J, Suematsu K, Nakamura J, Nagashima K. Gamma knife surgery for angiographically occult vascular malformations.  Stereotact Funct neurosurg. 1995;  64 (suppl 1) 98-109
• 41 Steiner L, Lindquist C, Adler J R, Torner J C, Alves W, Steiner M. Clinical outcome of radiosurgery for cerebral arteriovenous malformations.  J Neurosurg. 1992;  77 1-8
• 42 Strugar J, Rothbart D, Harrington W, Criscuolo G R. Vascular permeability factor in brain metastases: correlation with vasogenic brain edema and tumour angiogenesis.  J Neurosurg. 1994;  81 560-566
• 43 Vladyka V, Liščák R, Šimonová G, Šubrt O, Novotný J. Léčení nemocných s AVM gama nožem v nemocnici Na Homolce v prvních 3 letech.  Čes a Slov Neurol Neurochir. 1997;  60/93 253-260
• 44 Yoshioka H, Hama S, Taniguchi E, Sugiyama K, Arita K, Kurisu K. Peritumoural brain edema associated with meningioma, influence of vascular endothelial growth factor expression and vascular blood supply.  Cancer. 1999;  85 936-944
• 45 Zabramski J M, Wascher T M, Spetzler R F. et al . The natural history of familial cavernous malformations: results fo an ongoing study.  J Neurosurg. 1994;  80 422-432
• 46 Zimmerman R S, Spetzler R F, Lee K S, Zabramski J M, Hargraves R W. Cavernous malformations of the brain stem.  J Neurosurg. 1991;  75 32-39
• 47 Zvěřina E. Chirurgie cévních vaskulárních onemocnění mozku. In: Kalvach P et al. ed. Mozkové ischemie a hemoragie Praha: Grada Publishing 1997: 321-351

Corresponding Author