Department of Neurological Surgery and Center for Image-Guided Neurosurgery, University of Pittsburgh, Pennsylvania 15213, USA.
J Neurosurg. 2010 Jul;113(1):23-9. doi: 10.3171/2010.1.JNS081626.
A retrospective study was conducted to reassess the benefit and safety of stereotactic radiosurgery (SRS) in patients with solitary cerebral cavernous malformations (CCMs) that bleed repeatedly and are poor candidates for surgical removal.
Between 1988 and 2005 at the University of Pittsburgh, the authors performed SRS in 103 evaluable patients (57 males and 46 females) with solitary symptomatic CCMs. The mean patient age was 39.3 years. Ninety-eight percent of these patients had experienced 2 or more hemorrhages associated with new neurological deficits. Seventeen patients (16.5%) had undergone attempted resection before radiosurgery. Ninety-three CCMs were located in deep brain structures and 10 were in subcortical lobar areas of functional brain importance. The median malformation volume was 1.31 ml, and the median tumor margin dose was 16 Gy.
The follow-up ranged from 2 to 20 years. The annual hemorrhage rate--that is, a new neurological deficit associated with imaging evidence of a new hemorrhage--before SRS was 32.5%. After SRS 22 hemorrhages were observed within 2 years (10.8% annual hemorrhage rate) and 4 hemorrhages were observed after 2 years (1.06% annual hemorrhage rate). The risk of hemorrhage from a CCM was significantly reduced after radiosurgery (p < 0.0001). Overall, new neurological deficits due to adverse radiation effects following SRS developed in 14 patients (13.5%), with most occurring early in our experience. Modifications in technique (treatment volume within the T2-weighted MR imaging-defined margin, use of MR imaging, and dose reduction for CCM in critical brainstem locations) further reduced risks after SRS.
Data in this study provide further evidence that SRS is a relatively safe procedure that reduces the rebleeding rate for CCMs located in high-surgical-risk areas of the brain.
本回顾性研究旨在重新评估立体定向放射外科（SRS）治疗反复出血且不适合手术切除的单发脑海绵状血管畸形（CCM）患者的疗效和安全性。
1988 年至 2005 年，匹兹堡大学的研究人员对 103 例可评估的单发有症状 CCM 患者（57 名男性和 46 名女性）进行了 SRS 治疗。患者的平均年龄为 39.3 岁。其中 98%的患者有 2 次或以上与新的神经功能缺损相关的出血史。17 例（16.5%）患者在放射外科治疗前曾行尝试性切除术。93 个 CCM 位于深部脑结构，10 个位于重要功能脑皮质下叶区。畸形体积中位数为 1.31ml，肿瘤边缘剂量中位数为 16Gy。
随访时间为 2 至 20 年。SRS 治疗前的年出血率（即影像学证实新出血伴新发神经功能缺损）为 32.5%。SRS 后 2 年内观察到 22 次出血（10.8%的年出血率），2 年后观察到 4 次出血（1.06%的年出血率）。CCM 出血风险在放射外科治疗后显著降低（p<0.0001）。总体而言，14 例（13.5%）患者因放射外科治疗后出现不良反应而出现新的神经功能缺损，大多数发生在我们经验的早期。技术改进（T2 加权磁共振成像定义边缘内的治疗体积、磁共振成像的使用以及关键脑干位置 CCM 的剂量降低）进一步降低了 SRS 后的风险。
本研究数据进一步证明，SRS 是一种相对安全的治疗方法，可降低位于脑部高手术风险区域的 CCM 的再出血率。
