Document Detail


Stereotactic radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention. Clinical article.
MedLine Citation:
PMID:  20433275     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECT: The role of radiosurgery in the treatment of cavernous malformations (CMs) remains controversial. It is frequently recommended only for inoperable lesions that have bled at least twice. Rehemorrhage can carry a substantial risk of morbidity, however. The authors reviewed their practice of treating deep-seated inoperable CMs to assess the complication rate of radiosurgery, the impact that radiosurgery might have on rebleeding, and whether a more active, earlier intervention is justified in managing this condition. METHODS: The authors performed a retrospective analysis of 113 patients with 79 brainstem and 39 thalamic/basal ganglia CMs treated with Gamma Knife surgery. Lesions were stratified into 2 groups: those that might be lower risk with no more than 1 symptomatic bleed before radiosurgical treatment and those deemed high risk with multiple symptomatic hemorrhages before treatment. RESULTS: Forty-one CMs had multiple symptomatic hemorrhages before radiosurgery with a first-ever bleed rate of 2.9% per lesion per year, a rebleed rate of 30.5% per lesion per year, and a median time of 1.5 years between the first and second bleeds. In this group the rebleed rate decreased to 15% for the first 2 years after radiosurgery and declined further to 2.4% thereafter. Pretreatment multiple bleeds led to persistent deficits in 72% of the patients. Seventy-seven CMs had no more than 1 symptomatic bleed before radiosurgery, making for a lifetime bleed rate of 2.2% per lesion per year. The short period between the presenting bleed and treatment (median 1 year) makes the natural history in this group uncertain. The rate of hemorrhage in the first 2 years after treatment was 5.1%, and 1.3% thereafter. Pretreatment hemorrhages resulted in permanent deficits in 43% of the patients in this group, a rate significantly lower than in the multiple-bleeds group (p < 0.001). Posttreatment hemorrhages led to persistent deficits in only 7.3% of the patients. Permanent adverse radiation effects were rare (7.3%) and minor in both groups. CONCLUSIONS: Stereotactic radiosurgery is a safe management strategy for CMs in eloquent sites with the marked advantage of reducing rebleed risks in patients with repeated pretreatment hemorrhages. The benefit in treating CMs with a single bleed is less clear. Note, however, that repeated hemorrhage carries a significant risk of increased morbidity far in excess of any radiosurgery-related morbidity, and the authors assert that this finding justifies the early active management of deep-seated CMs.
Authors:
Gábor Nagy; Adam Razak; Jeremy G Rowe; Timothy J Hodgson; Stuart C Coley; Matthias W R Radatz; Umang J Patel; Andras A Kemeny
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Journal of neurosurgery     Volume:  113     ISSN:  1933-0693     ISO Abbreviation:  J. Neurosurg.     Publication Date:  2010 Oct 
Date Detail:
Created Date:  2010-10-04     Completed Date:  2010-10-28     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0253357     Medline TA:  J Neurosurg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  691-9     Citation Subset:  AIM; IM    
Affiliation:
The National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom.
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adult
Aged
Basal Ganglia Diseases / surgery
Brain Neoplasms / mortality,  surgery*
Brain Stem Neoplasms / surgery
Child
Child, Preschool
Follow-Up Studies
Hemangioma, Cavernous, Central Nervous System / mortality,  surgery*
Humans
Infant
Intracranial Arteriovenous Malformations / mortality,  surgery*
Intracranial Hemorrhages / epidemiology
Male
Middle Aged
Neurosurgical Procedures* / mortality
Patient Selection
Postoperative Complications / epidemiology,  mortality
Radiosurgery* / mortality
Risk Assessment
Thalamic Diseases / surgery
Young Adult
Comments/Corrections
Comment In:
J Neurosurg. 2010 Oct;113(4):689-90; discussion 690   [PMID:  20433271 ]

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