Stereotactic radiosurgery for symptomatic solitary cerebral cavernous malformations considered high risk for resection

Clinical article

L. Dade Lunsford Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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 M.D.
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Aftab A. Khan Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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Ajay Niranjan Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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Hideyuki Kano Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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John C. Flickinger Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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Douglas Kondziolka Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania

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 M.D., F.R.C.S.
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Object

A retrospective study was conducted to reassess the benefit and safety of stereotactic radiosurgery (SRS) in patients with solitary cerebral cavernous malformations (CCMs) that bleed repeatedly and are poor candidates for surgical removal.

Methods

Between 1988 and 2005 at the University of Pittsburgh, the authors performed SRS in 103 evaluable patients (57 males and 46 females) with solitary symptomatic CCMs. The mean patient age was 39.3 years. Ninety-eight percent of these patients had experienced 2 or more hemorrhages associated with new neurological deficits. Seventeen patients (16.5%) had undergone attempted resection before radiosurgery. Ninety-three CCMs were located in deep brain structures and 10 were in subcortical lobar areas of functional brain importance. The median malformation volume was 1.31 ml, and the median tumor margin dose was 16 Gy.

Results

The follow-up ranged from 2 to 20 years. The annual hemorrhage rate—that is, a new neurological deficit associated with imaging evidence of a new hemorrhage—before SRS was 32.5%. After SRS 22 hemorrhages were observed within 2 years (10.8% annual hemorrhage rate) and 4 hemorrhages were observed after 2 years (1.06% annual hemorrhage rate). The risk of hemorrhage from a CCM was significantly reduced after radiosurgery (p < 0.0001). Overall, new neurological deficits due to adverse radiation effects following SRS developed in 14 patients (13.5%), with most occurring early in our experience. Modifications in technique (treatment volume within the T2-weighted MR imaging–defined margin, use of MR imaging, and dose reduction for CCM in critical brainstem locations) further reduced risks after SRS.

Conclusions

Data in this study provide further evidence that SRS is a relatively safe procedure that reduces the rebleeding rate for CCMs located in high-surgical-risk areas of the brain.

Abbreviations used in this paper:

ARE = adverse radiation effects; AVM = arteriovenous malformation; CCM = cerebral cavernous malformation; DVA = developmental venous anomaly; SRS = stereotactic radiosurgery.
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  • 1

    Aiba T, , Tanaka R, , Koike T, , Kameyama S, , Takeda N, & Komata T: Natural history of intracranial cavernous malformations. J Neurosurg 83:5659, 1995

  • 2

    Amin-Hanjani S, , Ogilvy CS, , Candia GJ, , Lyons S, & Chapman PH: Stereotactic radiosurgery for cavernous malformations: Kjellberg's experience with proton beam therapy in 98 cases at the Harvard Cyclotron. Neurosurgery 42:12291238, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Barker FG II, , Amin-Hanjani S, , Butler WE, , Lyons S, , Ojemann RG, & Chapman PH, et al.: Temporal clustering of hemorrhages from untreated cavernous malformations of the central nervous system. Neurosurgery 49:1525, 2001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bertalanffy H, , Benes L, , Miyazawa T, , Alberti O, , Siegel AM, & Sure U: Cerebral cavernomas in the adult. Review of the literature and analysis of 72 surgically treated patients. Neurosurg Rev 25:155, 2002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chang SD, , Levy RP, , Adler JR Jr, , Martin DP, , Krakovitz PR, & Steinberg GK: Stereotactic radiosurgery of angiographically occult vascular malformations: 14-year experience. Neurosurgery 43:213221, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Chang SD, , Steinberg GK, , Levy RP, , Marks MP, , Frankel KA, & Shuster DL, et al.: Microsurgical resection of incompletely obliterated intracranial arteriovenous malformations following stereotactic radiosurgery. Neurol Med Chir (Tokyo) 38:Suppl 200207, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Del Curling O Jr, , Kelly DL Jr, , Elster AD, & Craven TE: An analysis of the natural history of cavernous angiomas. J Neurosurg 75:702708, 1991

  • 8

    García-Muñoz L, , Velasco-Campos F, , Lujan-Castilla P, , Enriquez-Barrera M, , Cervantes-Martínez A, & Carrillo-Ruiz J: [Radiosurgery in the treatment of brain cavernomas. Experience with 17 lesions treated in 15 patients.]. Neurochirurgie 53:243250, 2007. (Fr)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Gewirtz RJ, , Steinberg GK, , Crowley R, & Levy RP: Pathological changes in surgically resected angiographically occult vascular malformations after radiation. Neurosurgery 42:738743, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Hasegawa T, , McInerney J, , Kondziolka D, , Lee JY, , Flickinger JC, & Lunsford LD: Long-term results after stereotactic radiosurgery for patients with cavernous malformations. Neurosurgery 50:11901198, 2002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hauck EF, , Barnett SL, , White JA, & Samson D: Symptomatic brainstem cavernomas. Neurosurgery 64:6171, 2009

  • 12

    Karlsson B, , Kihlström L, , Lindquist C, , Ericson K, & Steiner L: Radiosurgery for cavernous malformations. J Neurosurg 88:293297, 1998

  • 13

    Kida Y, , Kobayashi T, & Mori Y: Radiosurgery of angiographically occult vascular malformations. Neurosurg Clin N Am 10:291303, 1999

  • 14

    Kim DG, , Choe WJ, , Paek SH, , Chung HT, , Kim IH, & Han DH: Radiosurgery of intracranial cavernous malformations. Acta Neurochir (Wien) 144:869878, 2002

  • 15

    Kondziolka D, , Lunsford LD, , Flickinger JC, & Kestle JR: Reduction of hemorrhage risk after stereotactic radiosurgery for cavernous malformations. J Neurosurg 83:825831, 1995

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kondziolka D, , Lunsford LD, & Kestle JR: The natural history of cerebral cavernous malformations. J Neurosurg 83:820824, 1995

  • 17

    Labauge P, , Brunereau L, , Lévy C, , Laberge S, & Houtteville JP: The natural history of familial cerebral cavernomas: a retrospective MRI study of 40 patients. Neuroradiology 42:327 332, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Larson JJ, , Ball WS, , Bove KE, , Crone KR, & Tew JM Jr: Formation of intracerebral cavernous malformations after radiation treatment for central nervous system neoplasia in children. J Neurosurg 88:5156, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Lindquist C, , Guo WY, , Karlsson B, & Steiner L: Radiosurgery for venous angiomas. J Neurosurg 78:531536, 1993

  • 20

    Liscák R, , Vladyka V, , Simonová G, , Vymazal J, & Novotny J Jr: Gamma knife surgery of brain cavernous hemangiomas. J Neurosurg 102:Suppl 207213, 2005

  • 21

    Liu KD, , Chung WY, , Wu HM, , Shiau CY, , Wang LW, & Guo WY, et al.: Gamma knife surgery for cavernous hemangiomas: an analysis of 125 patients. J Neurosurg 102:Suppl 8186, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Maraire JN, & Awad IA: Intracranial cavernous malformations: lesion behavior and management strategies. Neurosurgery 37:591605, 1995

  • 23

    Mathiesen T, , Edner G, & Kihlström L: Deep and brainstem cavernomas: a consecutive 8-year series. J Neurosurg 99:3137, 2003

  • 24

    McLaughlin MR, , Kondziolka D, , Flickinger JC, , Lunsford S, & Lunsford LD: The prospective natural history of cerebral venous malformations. Neurosurgery 43:195201, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Mitchell P, , Hodgson TJ, , Seaman S, , Kemeny AA, & Forster DM: Stereotactic radiosurgery and the risk of haemorrhage from cavernous malformations. Br J Neurosurg 14:96100, 2000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Moriarity JL, , Wetzel M, , Clatterbuck RE, , Javedan S, , Sheppard JM, & Hoenig-Rigamonti K, et al.: The natural history of cavernous malformations: a prospective study of 68 patients. Neurosurgery 44:11661173, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Muras I, , Conforti R, , Scuotto A, , Rinaldi F, & Bernini FP: Cerebral cavernous angioma. Diagnostic considerations. J Neuroradiol 20:3441, 1993

  • 28

    Nyáry I, , Major O, , Hanzély Z, & Szeifert GT: Histopathological findings in a surgically resected thalamic cavernous hemangioma 1 year after 40-Gy irradiation. J Neurosurg 102:Suppl 5658, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Nyáry I, , Major O, , Hanzély Z, & Szeifert GT: Pathological considerations to irradiation of cavernous malformations. Prog Neurol Surg 20:231234, 2007

  • 30

    Otten P, , Pizzolato GP, , Rilliet B, & Berney J: [131 cases of cavernous angioma (cavernomas) of the CNS, discovered by retrospective analysis of 24,535 autopsies.]. Neurochirurgie 35:8283, 128131, 1989. (Fr)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Pollock BE, , Garces YI, , Stafford SL, , Foote RL, , Schomberg PJ, & Link MJ: Stereotactic radiosurgery for cavernous malformations. J Neurosurg 93:987991, 2000

  • 32

    Porter PJ, , Willinsky RA, , Harper W, & Wallace MC: Cerebral cavernous malformations: natural history and prognosis after clinical deterioration with or without hemorrhage. J Neurosurg 87:190197, 1997

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Porter RW, , Detwiler PW, , Spetzler RF, , Lawton MT, , Baskin JJ, & Derksen PT, et al.: Cavernous malformations of the brainstem: experience with 100 patients. J Neurosurg 90:5058, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Samii M, , Eghbal R, , Carvalho GA, & Matthies C: Surgical management of brainstem cavernomas. J Neurosurg 95:825832, 2001

  • 35

    Zimmerman RS, , Spetzler RF, , Lee KS, , Zabramski JM, & Hargraves RW: Cavernous malformations of the brain stem. J Neurosurg 75:3239, 1991

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