Gamma Knife Radiosurgery in the Management of Arteriovenous Malformations of the Basal Ganglia Region of the Brain

Nicolato, A.; Foroni, Roberto; Crocco, Anna; Zampieri, P.; Alessandrini, F.; Bricolo, Albino; Gerosa, Massimo

doi:10.1055/s-2002-36200

Cited by 39 publications

(37 citation statements)

References 46 publications

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“…20,21,[24][25][26][27] Briefly, the MRI-compatible Leksell Model G stereotactic frame (Elekta Instruments) was applied to the patient's head. Then, neuroradiological localization was routinely performed using stereotactic 2D cerebral angiography or high-resolution magnification subtraction stereotactic angiograms.…”

Section: Radiosurgical Techniquesmentioning

confidence: 99%

“…8,25,41 Therefore, the "gold standard" treatment should be represented by complete surgical removal, with the aim of removing the risk of further, devastating hemorrhagic strokes. However, cAVMs are more frequently located in deep regions or in eloquent brain areas in children and adolescents (up to 70%-90% of the time) than in adults, 14,24,25,27,42,44 exposing these younger patients to high morbidity and mortality risks in the event of surgery.…”

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confidence: 99%

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Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months

Nicolato

Longhi

Tommasi

et al. 2015

PED

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J neurosurg Pediatr 16:736-747, 2015 abbreviations ARE = adverse radiation effects; cAVM = cerebral arteriovenous malformation; EE = endovascular embolization; GK = Gamma Knife; LINAC = linear accelerator; MD = maximal dose; OR = obliteration rate; PD = prescription dose; RS = radiosurgery; S-M = Spetzler-Martin; TOI = treatment obliteration interval. obJect The goal of this study was to evaluate advantages, risks, and failures of Gamma Knife radiosurgery (GKRS) in a large series of pediatric and adolescent patients with cerebral arteriovenous malformations (cAVMs) who were followed up for at least 36 months. methods Since February 1993, 100 pediatric and adolescent patients (≤ 18 years of age) with cAVMs have undergone GKRS at the authors' institution and were followed up for at least 36 months. Forty-six patients were boys and 54 were girls; the mean age was 12.8 years (range 3-18 years). Hemorrhage, either alone or combined with seizure, was the clinical onset in 70% of cases. The mean pre-GK cAVM volume was 2.8 ml; 92% of cAVMs were Spetzler-Martin (S-M) Grades I-III. Most lesions (94%) were in eloquent or deep-seated brain regions, according to S-M classification. The parameters for mean and range in treatment planning were prescription isodose 53.8% (40%-90%); prescription dose (PD) 20.2 Gy (9.0-26.4 Gy); maximal dose (MD) 37.8 Gy (18-50 Gy); and number of shots 4.7 (1-17). On the day of GKRS, stereotactic CT or stereotactic MRI and digital subtraction angiography were used. results Obliteration rate (OR) was angiographically documented in 75 of 84 cases (89.3%) after single-session GKRS, with actuarial ORs at 3 and 5 years of 68.0% and 88.1%, respectively. A repeat treatment was performed in 7 patients (6 with obliteration), and 16 patients with cAVMs underwent staged treatment (9 of them were angiographically cured). Thus, the overall OR was 90%, with actuarial ORs at 3, 5, and 8 years of 59.0%, 76.0%, and 85.0%, respectively. Permanent symptomatic GK-related complications were observed in 11% of cases, with surgical removal of enlarged mass seen on post-RS imaging needed in 5 cases. Hemorrhage during the latency period occurred in 9% of patients, but surgical evacuation of the hematoma was required in only 1 patient. One patient died due to rebleeding of a brainstem cAVM. Radiosurgery outcomes varied according to cAVM sizes and doses: volumes ≤ 10 ml and PDs > 16 Gy were significantly associated with higher ORs and lower rates of permanent complication and bleeding during the latency period. conclusions The data from this study reinforce the conclusion that GKRS is a safe and effective treatment for pediatric and adolescent cAVMs, yielding a high OR with minimal permanent severe morbidity and no mortality. The very low frequency of severe hemorrhages during the latency period further encourages a widespread application of RS in such patients. Univariate analysis found that modified RS-based cAVM score, nidus volume, PD, integral dose, S-M grade, and preplanned treatment (the last 2 parameters were al...

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Section: Radiosurgical Techniquesmentioning

confidence: 99%

mentioning

confidence: 99%

Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months

Nicolato

Longhi

Tommasi

et al. 2015

PED

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“…1,18,19,25,33,35 Pollock et al 33 reported that total obliteration of AVMs in the basal ganglia (10 cases), thalamus (30 cases), and brainstem (16 cases) was achieved in 24 (43%) of 56 patients after primary SRS at a median of 45 months. The actuarial rate of an AVM cure (including those confirmed by both angiography and MR imaging) after one or more radiosurgical procedures was 47% and 66% at 3 and 4 years after radiosurgery, respectively.…”

Section: Confirmation Of Avm Obliterationmentioning

confidence: 99%

“…1,18,19,25,33,35 The goal of SRS is complete obliteration of the AVM nidus while avoiding postprocedural ARE. Total obliteration rates after a single procedure vary between 60% and 80% over a 5-year period.…”

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Stereotactic radiosurgery for arteriovenous malformations, Part 4: management of basal ganglia and thalamus arteriovenous malformations

Kano

Kondziolka

Flickinger

et al. 2012

JNS

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Object The authors conducted a study to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) of the basal ganglia and thalamus. Methods Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 56 patients had AVMs of the basal ganglia and 77 had AVMs of the thalamus. In this series, 113 (85%) of 133 patients had a prior hemorrhage. The median target volume was 2.7 cm3 (range 0.1–20.7 cm3) and the median margin dose was 20 Gy (range 15–25 Gy). Results Obliteration of the AVM eventually was documented on MR imaging in 78 patients and on angiography in 63 patients in a median follow-up period of 61 months (range 2–265 months). The actuarial rates documenting total obliteration after radiosurgery were 57%, 70%, 72%, and 72% at 3, 4, 5, and 10 years, respectively. Factors associated with a higher rate of AVM obliteration included AVMs located in the basal ganglia, a smaller target volume, a smaller maximum diameter, and a higher margin dose. Fifteen (11%) of 133 patients suffered a hemorrhage during the latency period and 7 patients died. The rate of post-SRS AVM hemorrhage was 4.5%, 6.2%, 9.0%, 11.2%, and 15.4% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 4.7%. When 5 patients with 7 hemorrhages occurring earlier than 6 months after SRS were removed from this analysis, the annual hemorrhage rate decreased to 2.7%. Larger volume AVMs had a higher risk of hemorrhage after SRS. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 6 patients (4.5%), and in 1 patient a delayed cyst developed 56 months after SRS. No patient died of AREs. Factors associated with a higher risk of symptomatic AREs were larger target volume, larger maximum diameter, lower margin dose, and a higher Pollock-Flickinger score. Conclusions Stereotactic radiosurgery is a gradually effective and relatively safe management option for deep-seated AVMs in the basal ganglia and thalamus. Although hemorrhage after obliteration did not occur in the present series, patients remain at risk during the latency interval between SRS and obliteration. The best candidates for SRS are patients with smaller volume AVMs located in the basal ganglia.

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Pediatric Radiosurgery

Juloori¹,

Murphy²

2019

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

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Gamma Knife Radiosurgery in the Management of Arteriovenous Malformations of the Basal Ganglia Region of the Brain

Cited by 39 publications

References 46 publications

Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months

Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months

Stereotactic radiosurgery for arteriovenous malformations, Part 4: management of basal ganglia and thalamus arteriovenous malformations

Pediatric Radiosurgery

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