Outcome of intracerebral cavernoma treated by Gamma Knife radiosurgery based on a double-blind assessment of treatment indication

Abstract

Background The benefit and the risk profile of Gamma Knife radiosurgery (GKRS) for intracerebral cavernoma remains incompletely defined in part due to the natural history of low incidence of bleeding and spontaneous regression of this vascular malformation. In this study, we retrieved cases from a prospectively collected database to assess the outcome of intracerebral cavernoma treated with GKRS using a double blinded review process for treatment. Methods From 2003 to 2018, there were 94 cases of cavernoma treated by GKRS in the doubly blinded assessments by two experienced neurological and approved for GKRS treatment. All the patients received GKRS with margin dose of 11–12 (Gray) Gy and afterwards were assessed for neurological outcome, radiologic response, and quality of life. Results The median age of the patients was 48 (15–85) years with median follow up of 77 (26–180) months post SRS. The mean target volume was 1.93 ± 3.45 cc. In those who has pre-SRS epilepsy, 7 of 16 (43.7%) achieved seizure freedom (Engel I/II) and 9 of 16 (56.3%) achieved decreased seizures (Engel III) after SRS. Rebleeding occurred in 2 cases (2.1%) at 13 and 52 months post SRS. The radiologic assessment demonstrated 20 (21.3%) cases of decreased cavernoma volume, 69 (73.4%) were stable, and 5 (7.3%) increased size. Eighty-seven of 94 (92.5%) cases at the last follow up achieve improvement in their quality of life, but 7 cases (7.4%) showed a deterioration. In statistical analysis, the effective seizure control class (Engel I/II) was highly correlated with patient harboring a single lesion (p < 0.05) and deep seated location of the cavernoma (p < 0.01). New neurological deficits were highly correlated with decreased mental (p < 0.001) and physical (p < 0.05) components of quality of life testing, KPS (p < 0.001), deep seated location (p < 0.01), and increased nidus volume (p < 0.05). Quality of life deterioration either in physical component (p < 0.01), mental component (p < 0.01), and KPS (p < 0.05) was highly correlated with increased cavernoma volume. Conclusion Low margin dose GKRS for intracerebral cavernoma offers reasonable seizure control and improved quality of life while conferring a low risk of treatment complications including adverse radiation effect.

Management of Central Nervous System Cavernomas: An Experience of the Department of Neurosurgery at the Ibn Tofail Hospital, Mohammed VI University Hospital

“…Due to their variability in size, location, and hemorrhagic risk, they can cause a great spectrum of clinical symptoms. The most commonly encountered clinical symptoms are epilepsy followed by neurological deficit and headaches [ 1 , 3 - 5 , 6 ] which concords with our findings.…”

“…Due to their variability in size, location, and hemorrhagic risk, they can cause a great spectrum of clinical symptoms. The most commonly encountered clinical symptoms are epilepsy followed by neurological deficit and headaches [1,[3][4][5]6] which concords with our findings. MRI, though not the gold standard for diagnosis, is currently the most performing imaging tool, not only to pose a diagnosis but also for post-operative follow-up; MRI was performed on all our patients.…”

“…A conservative management is preferred in asymptomatic or mildly symptomatic patients, while complete resection is the only healing option for surgically accessible symptomatic or hemorrhagic lesions. The results obtained in our series concerning the treatment of epilepsy in operated patients concord with the results of the literature [ 3 , 13 - 15 ]. A total resection of the cavernoma was performed in all operated patients.…”

“…Cavernous angiomas can be found at any age but the majority of cases are diagnosed before the age of 60 with an age range of 30 to 50 years of age, and both sexes are equally affected (sex ratio=1) [ 1 , 3 ]. In our series, the mean age was 42, with a male predominance (62.5%).…”

“…It requires vast experience and perfect knowledge of surgical anatomy, and more precisely, the knowledge of surgical approaches with minimal risk. The strategy of the surgical approach is guided by the findings of MRI [ 3 ]. A conservative management is preferred in asymptomatic or mildly symptomatic patients, while complete resection is the only healing option for surgically accessible symptomatic or hemorrhagic lesions.…”