Stereotactic Linear Radiosurgery for Cavernous Angiomas

Abstract

Optimal management of symptomatic cavernous angiomas (CA) located in the thalamus and the brainstem is problematic. Clinical and radiological (MRI) follow-up series suggest that having hemorrhaged once, recurrent hemorrhage with progressive neurologic dysfunction may commonly occur. We have therefore chosen to treat these lesions when first symptomatic with stereotactic linear radiosurgery (SLR). We now report, after a median follow-up of 27 months, 12 patients with CAs (9 women, 3 men, mean age 40 years) treated in this fashion. Ten patients presented with hemorrhage (3 had more than one hemorrhage): two patients had new onset seizures. All patients had enhanced MRI/MRAs characteristic of CA. There were five brainstem and five thalamic CAs, and one each in the temporal lobe and insula. Cerebral angiograms were done in 8 patients for comparison with their respective MRAs. Only one CA was visualized in the late venous phase on cerebral angiogram and identical vascular features were appreciated on the MRA. The diameter of the CAs ranged from 1.0 to 3.0 cm with a mean of 1.6 cm. Dosimetry planning was based on MRI/CT features and the mean dose at the isocenter was 2.167 cGy (range = 2,000–2,500 cGy) delivered with a mean collimation diameter of 1.46 cm (range = 1.0–2.0 cm). All 12 patients continued to improve neurologically after SLR and had MRI-documented changes in their lesions: in general, the lesions became smaller and signal characteristics converted to methe-maglobin. However, 1 patient had an early post-SLR hemorrhage, documented by MRI, at 4.5 months. This patient''s lateral mesencephalic syndrome subsequently resolved and he was functionally improved, compared with baseline, at 22 months. Two patients developed hemiparesis at 7 and 9 months following SLR. One patient had a large pontine CA (2.0 cm) and the other a small peduncle CA (1.1 cm). Both patients had delayed brainstem radiation injury without rebleed documented on Gd-DTPA MRI. Three additional patients underwent SLR safety but have been followed less than 6 months each. Our experience suggests that radiosurgery for cavernous angioma protects against rebleed (though, as expected, not early rebleeds) as a recent study indicated a median of 12 months to recurrent hemorrhage. Delayed radiation injury may occur more frequently than expected from conventional dosimetry when this technique is used deep within the brain. We now target the lesion margins more conservatively by excluding the surrounding hemosiderin-stained parenchyma.

Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas

“…Thus far, only a few authors provided outcome data of patients treated with LINAC radiosurgery. Although the number of observed patients was significantly smaller, similar reductions of the annual hemorrhage rate were documented [36,46,47,48]. With an annual hemorrhage rate of 12.5% within the first 2 years after radiosurgery and 4.8% overall, our observations confirm these results.…”

Functional Results After Microsurgical Resection of Brain Stem Cavernous Malformations (Retrospective Study of a 12 Patient Series and Review of the Recent Literature)

“…This policy seemed to us logical especially when considering that CMs treated conservatively generally lead to severe disability and entail a mortality rate of the order of 20% [35]. The radiosurgical option, in spite of some articles claiming that radiosurgery might be e¨ective in CMs [13,28], did not prove to be e½cacious or even innocuous [2,11,26,29].…”

Radiosurgery for angiographically occult vascular malformations

“…Nearly 10-fold decreases in overall bleed rates were reported in the studies of Kim et al 26 and Tsien et al 61 On the other hand, postradiosurgery clinical event rates only decreased from 2.0 to 1.6% in the study of Liscák et al, 35 and data provided by Stea et al 57 did not demonstrate a significant decrease in hemorrhage rates.…”

“…24,35,44,46,57 Authors reported overall postradiosurgical hemorrhage rates ranging from 1.6 to 8%. This higher range may reflect insufficient follow-up as in the Kim et al…”