Reduction of hemorrhage risk after stereotactic radiosurgery for cavernous malformations

Douglas KondziolkaDepartments of Neurological Surgery and Radiation Oncology, Presbyterian University Hospital, and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and Division of Neurosurgery, Research Consulting Unit, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada

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L. Dade LunsfordDepartments of Neurological Surgery and Radiation Oncology, Presbyterian University Hospital, and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and Division of Neurosurgery, Research Consulting Unit, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada

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John C. FlickingerDepartments of Neurological Surgery and Radiation Oncology, Presbyterian University Hospital, and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and Division of Neurosurgery, Research Consulting Unit, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada

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John R. W. KestleDepartments of Neurological Surgery and Radiation Oncology, Presbyterian University Hospital, and the Center for Image-Guided Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania; and Division of Neurosurgery, Research Consulting Unit, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada

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✓ The benefits of radiosurgery for cavernous malformations are difficult to assess because of the unclear natural history of this vascular lesion, the inability to image malformation vessels, and the lack of an imaging technique that defines “cure.” The authors selected for radiosurgery 47 patients who harbored a hemorrhagic malformation in a critical intraparenchymal location remote from a pial or ependymal surface. Of these, 44 patients had experienced at least two hemorrhages before radiosurgery. The mean patient age was 39 years; six patients had previously undergone attempted surgical removal. The malformation was located in the pons/midbrain in 24 cases, the medulla in three, the thalamus in nine, the basal ganglia in three, deep in a parietal lobe in four, and deep in a temporal lobe in four. Patients had sustained initial hemorrhages from 0.5 to 12 years prior to radiosurgery (mean 4.12 years). In these patients, who were not typical of the majority of patients with cavernous malformations, there were 109 bleeds before radiosurgery in 193 prior observation-years, for a 56.5% annual hemorrhage rate (including the first hemorrhage), or an annual rate of 32% subsequent to the first hemorrhage.

The mean follow-up period after radiosurgery was 3.6 years (range 0.33–6.4 years). The proportion of patients with hemorrhage after radiosurgery was significantly reduced (p < 0.0001), as was the mean number of hemorrhages per patient (p = 0.00004). In the first 2 years after radiosurgery, there were seven bleeds in 80 observation-years (8.8% annual hemorrhage rate). In the 2- to 6-year interval after radiosurgery, the annual rate decreased to 1.1% (one bleed). After radiosurgery, 12 patients (26%) sustained neurological worsening that correlated with imaging changes. In eight patients these deficits were temporary; two underwent surgical resection and died. Two patients had new permanent deficits (4%). A significant reduction was observed in the hemorrhage rate after radiosurgery in patients who had deep hemorrhagic cavernous malformations, especially after a 2-year latency interval. This evidence provides further support to the belief that radiosurgery is an effective strategy for cavernous malformations, especially when located within the parenchyma of the brainstem or diencephalon.

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  • 1.

    Bertalanffy H, , Gilsbach JM, & Eggert HR, et al: Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir 108:9199, 1991 Bertalanffy H, Gilsbach JM, Eggert HR, et al: Microsurgery of deep-seated cavernous angiomas: report of 26 cases. Acta Neurochir 108:91–99, 1991

    • Search Google Scholar
    • Export Citation
  • 2.

    Coffey RJ, & Lunsford LD: Radiosurgery of cavernous malformations and other angiographically occult vascular malformations, in Awad AI, & Barrow DL (eds): Cavernous Malformations. Park Ridge, Ill: American Association of Neurological Surgeons, 1993, pp 187200 Coffey RJ, Lunsford Radiosurgery of cavernous malformations and other angiographically occult vascular malformations, in Awad AI, Barrow DL (eds): Cavernous Malformations. Park Ridge, Ill: American Association of Neurological Surgeons, 1993, pp 187–200

    • Search Google Scholar
    • Export Citation
  • 3.

    Curling OD Jr, , Kelly DL Jr, & Elster AD, et al: An analysis of the natural history of cavernous angiomas. J Neurosurg 75:702708, 1991 Curling OD Jr, Kelly DL Jr, Elster AD, et al: An analysis of the natural history of cavernous angiomas. J Neurosurg 75:702–708, 1991

    • Search Google Scholar
    • Export Citation
  • 4.

    Davis DH, & Kelly PJ: Stereotactic resection of occult vascular malformations. J Neurosurg 72:698702, 1990 Davis DH, Kelly PJ: Stereotactic resection of occult vascular malformations. J Neurosurg 72:698–702, 1990

    • Search Google Scholar
    • Export Citation
  • 5.

    Fahlbusch R, , Strauss C, & Huk W, et al: Surgical removal of pontomesencephalic cavernous hemangiomas. Neurosurgery 26:449457, 1990 Fahlbusch R, Strauss C, Huk W, et al: Surgical removal of pontomesencephalic cavernous hemangiomas. Neurosurgery 26:449–457, 1990

    • Search Google Scholar
    • Export Citation
  • 6.

    Giombini S, & Morello G: Cavernous angiomas of the brain. Account of fourteen personal cases and review of the literature. Acta Neurochir 40:6182, 1978 Giombini S, Morello G: Cavernous angiomas of the brain. Account of fourteen personal cases and review of the literature. Acta Neurochir 40:61–82, 1978

    • Search Google Scholar
    • Export Citation
  • 7.

    Isamat F, & Conesa G: Cavernous angiomas of the brain stem. Neurosurg Clin North Am 4:507518, 1993 Isamat F, Conesa G: Cavernous angiomas of the brain stem. Neurosurg Clin North Am 4:507–518, 1993

    • Search Google Scholar
    • Export Citation
  • 8.

    Kashiwagi S, , van Loveren HR, & Tew JM Jr, et al: Diagnosis and treatment of vascular brain-stem malformations. J Neurosurg 72:2734, 1990 Kashiwagi S, van Loveren HR, Tew JM Jr, et al: Diagnosis and treatment of vascular brain-stem malformations. J Neurosurg 72:27–34, 1990

    • Search Google Scholar
    • Export Citation
  • 9.

    Kondziolka D, , Dempsey PK, & Lunsford LD: The case for conservative management of venous angiomas. Can J Neurol Sci 18:295299, 1991 Kondziolka D, Dempsey PK, Lunsford LD: The case for conservative management of venous angiomas. Can J Neurol Sci 18:295–299, 1991

    • Search Google Scholar
    • Export Citation
  • 10.

    Kondziolka D, , Lunsford LD, & Coffey RJ, et al: Stereotactic radiosurgery of angiographically occult vascular malformations: indications and preliminary experience. Neurosurgery 27:892900, 1990 Kondziolka D, Lunsford LD, Coffey RJ, et al: Stereotactic radiosurgery of angiographically occult vascular malformations: indications and preliminary experience. Neurosurgery 27:892–900, 1990

    • Search Google Scholar
    • Export Citation
  • 11.

    Kondziolka D, , Lunsford LD, & Flickinger JC: Intraparenchymal brain stem radiosurgery. Neurosurg Clin North Am 4:469479, 1993 Kondziolka D, Lunsford LD, Flickinger JC: Intraparenchymal brain stem radiosurgery. Neurosurg Clin North Am 4:469–479, 1993

    • Search Google Scholar
    • Export Citation
  • 12.

    Kondziolka D, , Lunsford LD, & Kestle JR: The natural history of cerebral cavernous malformations. J Neurosurg 83:820824, 1995 Kondziolka D, Lunsford LD, Kestle JR: The natural history of cerebral cavernous malformations. J Neurosurg 83:820–824, 1995

    • Search Google Scholar
    • Export Citation
  • 13.

    LeDoux MS, , Aronin PA, & Odrezin GT: Surgically treated cavernous angiomas of the brain stem: report of two cases and review of the literature. Surg Neurol 35:395399, 1991 LeDoux MS, Aronin PA, Odrezin GT: Surgically treated cavernous angiomas of the brain stem: report of two cases and review of the literature. Surg Neurol 35:395–399, 1991

    • Search Google Scholar
    • Export Citation
  • 14.

    Lunsford LD, , Kondziolka D, & Flickinger JC, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512524, 1991 Lunsford LD, Kondziolka D, Flickinger JC, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512–524, 1991

    • Search Google Scholar
    • Export Citation
  • 15.

    Rigamonti D, , Drayer BP, & Johnson PC, et al: The MRI appearance of cavernous malformations (angiomas). J Neurosurg 67:518524, 1987 Rigamonti D, Drayer BP, Johnson PC, et al: The MRI appearance of cavernous malformations (angiomas). J Neurosurg 67:518–524, 1987

    • Search Google Scholar
    • Export Citation
  • 16.

    Rigamonti D, & Spetzler RF: The association of venous and cavernous malformations. Report of four cases and discussion of the pathophysiological, diagnostic, and therapeutic implications. Acta Neurochir 92:100105, 1988 Rigamonti D, Spetzler RF: The association of venous and cavernous malformations. Report of four cases and discussion of the pathophysiological, diagnostic, and therapeutic implications. Acta Neurochir 92:100–105, 1988

    • Search Google Scholar
    • Export Citation
  • 17.

    Robinson JR, , Awad IA, & Little JR: Natural history of the cavernous angioma. J Neurosurg 75:709714, 1991 Robinson JR, Awad IA, Little JR: Natural history of the cavernous angioma. J Neurosurg 75:709–714, 1991

    • Search Google Scholar
    • Export Citation
  • 18.

    Robinson JR Jr, , Awad IA, & Masaryk TJ, et al: Pathological heterogeneity of angiographically occult vascular malformations of the brain. Neurosurgery 33:547555, 1993 Robinson JR Jr, Awad IA, Masaryk TJ, et al: Pathological heterogeneity of angiographically occult vascular malformations of the brain. Neurosurgery 33:547–555, 1993

    • Search Google Scholar
    • Export Citation
  • 19.

    Roda JM, , Alvarez F, & Isla A, et al: Thalamic cavernous malformations. Case report. J Neurosurg 72:647649, 1990 Roda JM, Alvarez F, Isla A, et al: Thalamic cavernous malformations. Case report. J Neurosurg 72:647–649, 1990

    • Search Google Scholar
    • Export Citation
  • 20.

    Scott BB, , Seeger JF, & Schneider RC: Successful evacuation of a pontine hematoma secondary to rupture of a pathologically diagnosed “cryptic” vascular malformation. Case report. J Neurosurg 39:104108, 1973 Scott BB, Seeger JF, Schneider RC: Successful evacuation of a pontine hematoma secondary to rupture of a pathologically diagnosed “cryptic” vascular malformation. Case report. J Neurosurg 39:104–108, 1973

    • Search Google Scholar
    • Export Citation
  • 21.

    Scott RM, , Barnes P, & Kupsky W, et al: Cavernous angiomas of the central nervous system in children. J Neurosurg 76:3846, 1992 Scott RM, Barnes P, Kupsky W, et al: Cavernous angiomas of the central nervous system in children. J Neurosurg 76:38–46, 1992

    • Search Google Scholar
    • Export Citation
  • 22.

    Seifert V, & Gaab MR: Laser-assisted microsurgical extirpation of a brain stem cavernoma: case report. Neurosurgery 25:986990, 1989 Seifert V, Gaab MR: Laser-assisted microsurgical extirpation of a brain stem cavernoma: case report. Neurosurgery 25:986–990, 1989

    • Search Google Scholar
    • Export Citation
  • 23.

    Shah MV, & Heros RC: Microsurgical treatment of supratentorial lesions, in Awad AI, & Barrow DL (eds): Cavernous Malformations. Park Ridge, Ill: American Association of Neurological Surgeons, 1993, pp 101116 Shah MV, Heros RC: Microsurgical treatment of supratentorial lesions, in Awad AI, Barrow DL (eds): Cavernous Malformations. Park Ridge, Ill: American Association of Neurological Surgeons, 1993, pp 101–116

    • Search Google Scholar
    • Export Citation
  • 24.

    Tung H, , Giannotta SL, & Chandrasoma PT, et al: Recurrent intraparenchymal hemorrhages from angiographically occult vascular malformations. J Neurosurg 73:174180, 1990 Tung H, Giannotta SL, Chandrasoma PT, et al: Recurrent intraparenchymal hemorrhages from angiographically occult vascular malformations. J Neurosurg 73:174–180, 1990

    • Search Google Scholar
    • Export Citation
  • 25.

    Vaquero J, , Salazar J, & Martínez R, et al: Cavernomas of the central nervous system: clinical syndromes, CT scan diagnosis, and prognosis after surgical treatment in 25 cases. Acta Neurochir 85:2933, 1987 Vaquero J, Salazar J, Martínez R, et al: Cavernomas of the central nervous system: clinical syndromes, CT scan diagnosis, and prognosis after surgical treatment in 25 cases. Acta Neurochir 85:29–33, 1987

    • Search Google Scholar
    • Export Citation
  • 26.

    Yoshimoto T, & Suzuki J: Radical surgery on cavernous angioma of the brainstem. Surg Neurol 26:7278, 1986 Yoshimoto T, Suzuki J: Radical surgery on cavernous angioma of the brainstem. Surg Neurol 26:72–78, 1986

    • Search Google Scholar
    • Export Citation
  • 27.

    Zimmerman RS, , Spetzler RF, & Lee KS, et al: Cavernous malformations of the brain stem. J Neurosurg 75:3239, 1991 Zimmerman RS, Spetzler RF, Lee KS, et al: Cavernous malformations of the brain stem. J Neurosurg 75:32–39, 1991

    • Search Google Scholar
    • Export Citation

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