J Korean Med Sci.  2024 Aug;39(32):e229. 10.3346/jkms.2024.39.e229.

Long-Term Outcomes of Gamma Knife Radiosurgery for Cerebral Cavernous Malformations: 10 Years and Beyond

• Myeong HS
• Jeong SS
• Kim JH
• Lee JM
• Park KH
• Park K
• Park HJ
• Park HR
• Yoon BW
• Lee EJ
• Kim JW
• Chung HT
• Kim DG
• Paek SH

• KMID: 2558529
• DOI: http://doi.org/10.3346/jkms.2024.39.e229

Abstract

Background
We aimed to evaluate long-term outcomes of gamma knife radiosurgery (GKS) for cerebral cavernous malformations (CCMs).
Methods
Among the 233 CCM patients who underwent GKS, 79 adult patients (96 lesions) followed for over 10 years were included and analyzed retrospectively. Annual hemorrhage rate (AHR) was analyzed the entire cohort of 233 patients and the subset of 79 enrolled patients by dividing lesions into overall CCM lesions and brainstem lesions. AHR, neurologic outcome, adverse radiation effect (ARE), and changes of lesions in magnetic resonance imaging (MRI) were compared before and after GKS. Cox-regression analysis was performed to identify risk factors for hemorrhage following GKS.
Results
Mean follow-up duration of 79 enrolled patients was 14 years (range, 10–23 years). The AHR of all CCMs for entire cohort at each time point was 17.8% (pre-GKS), 5.9% (≤ 2 years post-GKS), 1.8% (≤ 10 years post-GKS). The AHR of all CCM for 79 enrolled patients was 21.4% (pre-GKS), 3.8% (2 years post-GKS), 1.4% (10 years post-GKS), and 2.3% (> 10 years post-GKS). The AHR of brainstem cavernous malformation (CM) for entire cohort at each time point was 22.4% (pre-GKS), 10.1% (≤ 2 years post-GKS), 3.2% (≤ 10 years post-GKS). The AHR of brainstem CM for 79 enrolled patients was 27.2% (pre-GKS), 5.8% (2 years post-GKS), 3.4% (10 years post-GKS), and 3.5% (> 10 years post-GKS). Out of the 79 enrolled patients, 35 presented with focal neurologic deficits at the initial clinical visit. Among these patients, 74.3% showed recovery at the last follow-up. Symptomatic ARE occurred in five (6.4%) patients. No mortality occurred. Most lesions were decreased in size at the last follow-up MRI. Previous hemorrhage history (hazard ratio [HR], 8.38; 95% confidence interval [CI], 1.07–65.88; P = 0.043), and brainstem location (HR, 3.10; 95% CI, 1.26–7.64; P = 0.014) were significant risk factors for hemorrhage event.
Conclusion
GKS for CCM showed favorable long-term outcomes. GKS should be considered for CCM, especially when it has a previous hemorrhage history and brainstem location.

Keyword

Cerebral Cavernous Malformation; Gamma Knife Radiosurgery; Long-term Outcomes; Annual Hemorrhage Rate; Adverse Radiation Effect

Figure

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  Fig. 1 Annual hemorrhage rates of all cerebral cavernous malformations and brainstem cavernous malformations following GKS. The annotation GKS(T) includes the entire cohort at a given time point. The annotation GKS(S) pertains only to 79 patients who were followed-up for more than 10 years and were included in this study. The annotation Pre-GKS(T) includes 233 patients. ≤ 2 years GKS(T) includes 212 patients after excluding 21 patients who only underwent GKS without further follow-ups. ≤ 10 years GKS(T) includes 173 patients.GKS = gamma knife radiosurgery, CCM = cerebral cavernous malformation, CM = cavernous malformation.

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  Fig. 2 Shrinkage of lesion after extensive perilesional edema in brain MRI. A 2.3 cm3 cavernous malformation in the right frontal lobe was detected in a patient presented with seizure. GKS was performed with a marginal dose of 17 Gy to the 50% isodose lime. After 8 months of GKS, the patient presented to the emergency room with severe headache. Extensive perilesional edema with increased volume of cavernous malformation due to hemorrhage was found in brain MRI. The patient received short-term steroid therapy. At 15 months after GKS, the perilesional edema disappeared completely and the volume of cavernous malformation was significantly reduced.GKS = gamma knife radiosurgery, MRI = magnetic resonance imaging.

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  Fig. 3 Volume reduction and stabilization of cerebral cavernous malformation after GKS. A 6.4 cm3 cavernous malformation in the right midbrain was detected in a patient presented with left hemiparesis. GKS was performed with a marginal dose of 13 Gy to the 50% isodose line. Serial T2-weighted magnetic resonance imaging shows progressive volume reduction and obliteration of the core portion.GKS = gamma knife radiosurgery.

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