Stereotactic radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention. Clinical article

J Neurosurg. 2010 Oct;113(4):691-9. doi: 10.3171/2010.3.JNS091156.


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.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Basal Ganglia Diseases / surgery
  • Brain Neoplasms / mortality
  • Brain Neoplasms / surgery*
  • Brain Stem Neoplasms / surgery
  • Child
  • Child, Preschool
  • Follow-Up Studies
  • Hemangioma, Cavernous, Central Nervous System / mortality
  • Hemangioma, Cavernous, Central Nervous System / surgery*
  • Humans
  • Infant
  • Intracranial Arteriovenous Malformations / mortality
  • Intracranial Arteriovenous Malformations / surgery*
  • Intracranial Hemorrhages / epidemiology
  • Male
  • Middle Aged
  • Neurosurgical Procedures* / mortality
  • Patient Selection
  • Postoperative Complications / epidemiology
  • Postoperative Complications / mortality
  • Radiosurgery* / mortality
  • Risk Assessment
  • Thalamic Diseases / surgery
  • Young Adult