J Korean Neurosurg Soc.  2015 Jul;58(1):83-88. 10.3340/jkns.2015.58.1.83.

Growing Organized Hematomas Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation : Five Cases of Surgical Excision

• Park JC
• Ahn JS
• Kwon DH
• Kwun BD

• KMID: 2067111
• DOI: http://doi.org/10.3340/jkns.2015.58.1.83

Abstract

Organized hematoma is a rare complication that can develop following gamma knife radiosurgery (GKS) for cerebral arteriovenous malformation (AVM). Here, we describe 5 patients with growing organized hematomas that developed from completely obliterated AVMs several years after GKS. The patients were 15, 16, 30, 36, and 38 years old at the time of GKS, respectively, and 3 patients were female. Four AVMs were located in the lobe of the brain, and the remaining AVM were in the thalamus. Between 2-12 years after GKS, patients developed progressive symptoms such intractable headache or hemiparesis and enhancing mass lesions were identified. Follow-up visits revealed the slow expansion of the hematomas and surrounding edema. Steroids were ineffective, and thus surgery was performed. Histology revealed organized hematomas with a capsule, but there was no evidence of residual AVMs or vascular malformation. After surgery, the neurological symptoms of all patients improved and the surrounding edema resolved. However, the hematoma continued to expand and intraventricular hemorrhage developed in 1 patient whose hematoma was only partially removed. GKS for cerebral AVM can be complicated by growing, organized hematomas that develop after complete obliteration. Growing hematomas should be surgically evacuated if they are symptomatic. Radical resection of the hematoma capsule is also strongly recommended.

Keyword

Gamma knife radiosurgery; Intracranial arteriovenous malformation; Intracranial hemorrhage; Surgical procedure

MeSH Terms

Brain
Edema
Female
Follow-Up Studies
Headache Disorders
Hematoma*
Hemorrhage
Humans
Intracranial Arteriovenous Malformations*
Intracranial Hemorrhages
Paresis
Radiosurgery*
Steroids
Thalamus
Vascular Malformations
Steroids

Figure

• 

  Fig. 1 Images obtained during the clinical course of patient 2. A and B : Axial T2-weighted image and right internal carotid angiograms showing a residual arteriovenous malformation (AVM) in the right frontal lobe at 4 years after the first gamma knife surgery (GKS). C : Right internal carotid angiograms obtained 29 months after the second GKS. Residual AVM was not observed. D : T2-weighted magnetic resonance image (MRI) obtained 7 years after the second GKS and after the patient developed hemiparesis. Edema surrounding the obliterated AVM is shown. E : T2-weighted MRI obtained 7 months after the preceding MRI revealed that the heterogenous signal mass lesion had expanded and the edema was even more intense. F : T2-weighted MRI obtained 2 months after surgical excision. The mass lesion was not observed and the mass effect improved.

• 

  Fig. 2 Histological results for the specimen resected from patient 2. A : Gross image showing that the tough capsule contained xanthochromic fluid, thrombosis, and fibrotic tissue. B : Hematoxylin and eosin-stained specimen. Multi-stage clots with hemosiderin deposits and fresh hemorrhage (×100 original magnification). C : Hematoxylin and eosin-stained specimen. The hematoma contained fibrotic and degenerated vessels (arrows), which are suggestive of obliterated arteriovenous malformation vessels (×12.5 original magnification).

• 

  Fig. 3 Images obtained during the clinical course of patient 3. A and B : Axial T2-weighted image and left vertebral angiograms showing the presence of an arteriovenous malformation (AVM) in the left thalamus and posterior hippocampal gyrus. C : Vertebral angiogram obtained 5 years after gamma knife surgery (GKS) showing no residual AVM. D : A cyst developed 6 years after GKS and an Ommaya reservoir was inserted. E : T2-weighted magnetic resonance image (MRI) obtained 12 years after GKS when the patient developed left hemiparesis and severe headache, which shows a heterogenous signal mass and extensive surrounding edema without an enlarged cyst. F : Computed tomography performed 11 months after subtotal resection revealed that the hematoma had expanded again and confirmed the presence of intraventricular hemorrhage.

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