Manish Kumar Kasliwal and Ashish Suri
Narayanam Anantha Sai Kiran, Shashank Sharad Kale, Sandeep Vaishya, Manish Kumar Kasliwal, Aditya Gupta, Manish Singh Sharma, Bhavani Shankar Sharma and Ashok Kumar Mahapatra
This retrospective study was designed to study the outcome in children with intracranial arteriovenous malformations (AVMs) treated with Gamma Knife surgery (GKS).
One hundred and forty-two children were treated with GKS at the authors' institution between April 1997 and March 2006; of these, 103 patients with a mean follow-up of 26.4 months (range 6–96 months) were included. The mean age at presentation was 13.9 years (range 3–18 years). Eighty-six (83%) patients presented with hemorrhage. In 57 children the AVMs were Spetzler–Martin Grade I or II, and in 46 the AVMs were Grades III, IV, or V. The mean volume of the AVMs was 2.4 ml (range 0.04–23.3 ml). The mean marginal dose administered was 24.4 Gy (range 15–27 Gy). Follow-up angiography was advised at 2 years after GKS and yearly thereafter. In patients with residual AVMs, follow-up angiography was advised yearly until 4 years after GKS. If residual AVM was present, even on a follow-up angiogram obtained 4 years postsurgery, the GKS was considered a failure.
Complete obliteration of the AVM was documented in 34 (87%) of the 39 patients with complete angiographic follow-up. The 3- and 4-year actuarial rates of nidus obliteration were 66 and 86% respectively. Three patients (2.9%) experienced bleeding during the latency period, and symptomatic radiation-induced edema was noted in four patients (3.8%). A significantly higher incidence of radiation edema was noted in patients with AVM volumes greater than 3 ml and in patients with Spetzler–Martin Grade IV and V AVMs.
Gamma Knife radiosurgery is an effective modality for the treatment of intracranial AVMs in children, yielding high obliteration rates and low complication rates.
Manish Kumar Kasliwal, Shashank Sharad Kale, Aditya Gupta, Narayanam Anantha Sai Kiran, Manish Singh Sharma, Bhawani Shanker Sharma and Ashok K. Mahapatra
Although the effects of Gamma Knife surgery (GKS) on the risk of hemorrhage are poorly understood, a certain subset of patients does suffer bleeding after GKS. This study was undertaken to analyze the outcome of patients sustaining hemorrhage after GKS; it is the most feared complication of radiosurgical management of cerebral arteriovenous malformations (AVMs).
Between May 1997 and June 2006, 494 cerebral AVMs in 489 patients were treated using a Leksell Gamma Knife Model B, and follow-up evaluations were conducted until June 2007 at the All India Institute of Medical Sciences in New Delhi. Fourteen patients who sustained a hemorrhage after GKS formed the study group. In most of these patients conservative management was chosen.
The mortality rate was 0% and there was a 7% risk of sustaining a severe deficit following rebleeding after GKS. None of the patients sustained rebleeding after complete obliteration. Patients with Spetzler-Martin Grade III or less had increased chances of hemorrhage after GKS (p < 0.002). The presence of deep venous drainage, aneurysm, venous hypertension, or periventricular location on angiography was common in patients with hemorrhage after GKS.
The risk of hemorrhage that remains following GKS for cerebral AVMs is highest in the 1st year after treatment. The present study showed a relatively good outcome even in cases with hemorrhage following GKS, with no deaths and minimal morbidity, further substantiating the safety and efficacy of the procedure.