Management and outcome of hemorrhage after Gamma Knife surgery for arteriovenous malformations of the brain

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Appropriate management of hemorrhage after Gamma Knife surgery (GKS) for arteriovenous malformations (AVMs) of the brain is poorly understood, although a certain proportion of patients suffer from hemorrhage.


Among 500 patients observed for 1 to 183 months (median 70 months) after GKS, 32 patients (6.4%) suffered a hemorrhage. Hemorrhage developed even after angiographically documented obliteration of the AVM in five (2%) of 250 patients followed for 1 to 133 months (median 75 months) post-GKS. These patients had been treated according to their pathological condition. Treatment of these patients and their outcomes were retrospectively reviewed. As a management strategy in patients with preobliteration hemorrhage, the intracerebral hematoma and the AVM nidus were removed in four patients, and chronic encapsulated hematoma was removed in three. Among 11 patients who were conservatively treated, AVMs were ultimately obliterated in five, including three patients who underwent repeated GKS. Intracerebral hematoma from angiographically documented obliterated AVMs was radically resected in two patients, including one who also underwent aspiration of an accompanying symptomatic cyst. Intraoperative bleeding was easily controlled in these patients. Outcomes after hemorrhage, measured with the modified Rankin Scale, were significantly better in patients with postobliteration hemorrhage than in those with preobliteration hemorrhage (p < 0.05).


Various types of hemorrhagic complications after GKS for AVMs can be properly managed based on an understanding of each pathological condition. Although a small risk of bleeding remains after angiographically demonstrated obliteration, surgery for such AVMs is safe, and the patient outcomes are more favorable. Radical resection to prevent further hemorrhage is recommended for ruptured AVMs after obliteration because such AVMs can cause repeated hemorrhages.

Abbreviations used in this paper: AVM = arteriovenous malformation; GKS = Gamma Knife surgery; ICH = intracerebral hematoma; mRS = modified Rankin Scale.

Article Information

This work was supported in part by grants-in-aid for scientific research awarded to Dr. Maruyama from the Ministry of Education, Science, and Culture of Japan (Grant No. 18791013). Address reprint requests to: Keisuke Maruyama, M.D., Ph.D., Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. email:

© AANS, except where prohibited by US copyright law.



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    Graph showing Kaplan–Meier curves of hemorrhage rates following GKS for obliterated and nonobliterated AVMs.

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    Contrast-enhanced computerized tomography (CT) scan (A) and right internal carotid arteriogram, anteroposterior view (B) obtained during GKS in a 51-year-old man in whom an AVM had been incidentally diagnosed in the right caudate. Six years after 22.5 Gy was delivered to the AVM margin, he reported a headache. A CT scan revealed chronic encapsulated ICH (C). The ICH produced diffuse white matter changes on a T2-weighted magnetic resonance image (D). After surgical removal of the ICH, the diffuse white matter changes regressed (E and F).

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    Left internal carotid artery angiogram, lateral view (A), vertebral artery angiogram (B), and a T2-weighted magnetic resonance image (C) obtained in a 28-year-old woman, revealing an AVM in the left basal ganglia. Although the AVM was obliterated after two sessions of GKS, acute intracerebral hemorrhage was observed near the original AVM 83 months later on a CT scan (D) without a residual AVM or any other abnormal vessels on both carotid (E) and vertebral (F) artery angiograms. This hemorrhage was conservatively managed, given the risk of worsening existing motor function and aphasia.


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