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Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas

Stereotaktische LINAC-Radiochirurgie zur Behandlung von Hirnstammkavernomen

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Abstract

Background

The management of deep-seated cerebral cavernous malformations (CCMs) is still controversial. Although surgery remains the treatment of choice in patients with recurrent hemorrhage, patients with CCMs located in the brainstem are in many cases not eligible for resection due to high procedure-related morbidity and mortality. We evaluated the long-term outcome of LINAC radiosurgery (LINAC-RS) for the treatment of brainstem CCMs.

Patients and methods

Between December 1992 and March 2008, 14 patients (6 men, 8 women) harboring brainstem CCMs underwent LINAC-RS. Pretreatment neuroimaging showed no associated developmental venous angiomas (DVAs) in any of our patients. Prior to treatment, all patients suffered at least from one symptomatic hemorrhage (median 1.8, range 1–3). A median follow-up of 7.1 years (range 2.0–16.8 years) could be obtained in 12 patients. We applied a median tumor surface dose of 13.9 Gy (range 11–18 Gy; median tumor volume 1.6 ml, range 0.4–4.3 ml).

Results

Following LINAC-RS, neurological outcome improved in 4 (33.3%) and remained unchanged in 8 patients (66.7%). Rebleeding with subsequent transient neurological status deterioration occurred in 4 patients (33.3%), leading to additional surgical resection in 2 patients (16.7%). The corresponding annual hemorrhage rate was 4.8% (4/82.8 patient–years). Adverse radiation effects (ARE, defined by perilesional hyperintensity on T2-weighted MR images) were revealed in 3 patients (25%), leading to transient neurological deficits in 2 patients (16.7%). There were no procedure-related complications leading to either permanent morbidity or mortality.

Conclusion

Our results support the role of LINAC-RS as an efficient and safe treatment to significantly reduce the annual hemorrhage rate in patients suffering from brainstem CCMs not eligible to microsurgery. Compared with radiosurgery for arteriovenous malformations (AVMs), the intervention-related morbidity is higher.

Zusammenfassung

Hintergrund

Die Behandlung von tiefsitzenden, zerebralen kavernösen Malformationen (CCM) ist noch umstritten. Die Operation ist die Therapie der Wahl bei Patienten mit rezidivierenden Blutungen, jedoch aufgrund der Lokalisation im Hirnstamm in vielen Fällen mit einer hohen Morbiditäts- und Mortalitätsrate verbunden. Wir präsentieren in dieser Studie unsere Langzeitergebnisse der LINAC-Radiochirurgie (LINAC-RS) für die Behandlung von Hirnstammkavernomen.

Patienten und Methoden

Zwischen Dezember 1992 und März 2008, wurden 14 Patienten (6 Männer, 8 Frauen) mit Hirnstammkavernomen mittels LINAC-RS behandelt. In allen Patienten zeigten MRT-Voraufnahmen kein assoziiertes venöses Angiom („developmental venous angiomas“, DVA). Vor der Behandlung hatten alle Patienten mindestens 1 symptomatische Blutung (Median: 1,8 Blutungen; Wertebereich: 1–3 Blutungen) erlitten. Eine mediane Nachbeobachtungszeit von 7,1 Jahren (2,0–16,8 Jahre) konnte bei 12 Patienten erzielt werden. Es wurde eine mediane Tumoroberflächendosis von 13,9 Gy (11–18 Gy) bei einem medianen Tumorvolumen von 1,6 ml (0,4–4,3 ml) appliziert.

Ergebnisse

Nach der LINAC-RS verbesserten sich die neurologischen Symptome bei 4 Patienten (33,3%) und blieben unverändert bei 8 Patienten (66,7%). Eine Nachblutung mit anschließender vorübergehender neurologischer Verschlechterung des Zustands trat bei 4 Patienten (33,3%) auf, welche bei 2 Patienten (16,7%) zu einer anschließenden chirurgischen Resektion führte. Die entsprechende jährliche Blutungsrate lag bei 4,8% (4/82,8 Patientenjahre). Strahleninduzierte Nebenwirkungen („adverse radiation effects“, ARE, definiert durch periläsionale Hyperintensitäten auf T2-gewichteten MRT-Bildern) zeigten sich bei 3 Patienten (25%), was zu vorübergehenden neurologischen Defiziten bei 2 Patienten (16,7%) führte. Es gab keine therapiebedingten Komplikationen sowie keine permanente Morbidität oder Mortalität.

Schlussfolgerung

Unsere Ergebnisse zeigen die Effizienz und Sicherheit der LINAC-RS zur Reduzierung der jährlichen Blutungsrate bei Patienten mit Hirnstammkavernomen. Verglichen mit der Radiochirurgie für arteriovenöse Malformationen (AVM) zeigt sich eine erhöhte therapieassoziierte Morbidität.

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The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany

    M. Fuetsch, F. El Majdoub, M. Hoevels, V. Sturm & M. Maarouf M.D.

  2. Department of Radiation Oncology, University of Cologne, Cologne, Germany

    R.P. Müller

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  1. M. Fuetsch
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  2. F. El Majdoub
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  3. M. Hoevels
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  4. R.P. Müller
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  5. V. Sturm
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  6. M. Maarouf M.D.
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Correspondence to M. Maarouf M.D..

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The first two authors contributed equally to this work.

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Fuetsch, M., El Majdoub, F., Hoevels, M. et al. Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas. Strahlenther Onkol 188, 311–318 (2012). https://doi.org/10.1007/s00066-011-0050-7

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