Steinberg G K, Fabrikant J I, Marks M P, Levy R P, Frankel K A, Phillips M H, Shuer L M, Silverberg G D
Division of Neurosurgery, Stanford University, School of Medicine, Calif. 94305.
N Engl J Med. 1990 Jul 12;323(2):96-101. doi: 10.1056/NEJM199007123230205.
Heavy-charged-particle radiation has several advantages over protons and photons for the treatment of intracranial lesions; it has an improved physical distribution of the dose deep in tissue, a small angle of lateral scattering, and a sharp distal falloff of the dose.
We present detailed clinical and radiologic follow-up in 86 patients with symptomatic but surgically inaccessible cerebral arteriovenous malformations that were treated with stereotactic helium-ion Bragg-peak radiation. The doses ranged from 8.8 to 34.6 Gy delivered to volumes of tissue of 0.3 to 70 cm3.
Two years after radiation treatment, the rate of complete obliteration of the lesions, as detected angiographically, was 94 percent for lesions smaller than 4 cm3, 75 percent for those of 4 to 25 cm3, and 39 percent for those larger than 25 cm3. After three years, the rates of obliteration were 100, 95, and 70 percent, respectively. Major neurologic complications occurred in 10 patients (12 percent), of whom 8 had permanent deficits. All these complications occurred in the initial stage of the protocol, before the maximal dose of radiation was reduced to 19.2 Gy. In addition, hemorrhage occurred in 10 patients from residual malformations between 4 and 34 months after treatment. Seizures and headaches were less severe in 63 percent of the 35 and 68 percent of the 40 patients, respectively, who had them initially.
Given the natural history of these inaccessible lesions and the high risks of surgery, we conclude that heavy-charged-particle radiation is an effective therapy for symptomatic, surgically inaccessible intracranial arteriovenous malformations. The current procedure has two disadvantages: a prolonged latency period before complete obliteration of the vascular lesion and a small risk of serious neurologic complications.
与质子和光子相比，重带电粒子辐射在治疗颅内病变方面具有多个优势；它在组织深部的剂量物理分布更佳，侧向散射角度小，且剂量在远端急剧下降。
我们对86例有症状但手术难以触及的脑动静脉畸形患者进行了详细的临床和放射学随访，这些患者接受了立体定向氦离子布拉格峰辐射治疗。给予0.3至70立方厘米组织体积的剂量范围为8.8至34.6戈瑞。
放射治疗两年后，血管造影检测到的病变完全闭塞率，对于小于4立方厘米的病变为94%，4至25立方厘米的病变为75%，大于25立方厘米的病变为39%。三年后，闭塞率分别为100%、95%和70%。10例患者（12%）发生了严重神经并发症，其中8例有永久性缺陷。所有这些并发症均发生在方案的初始阶段，即在最大辐射剂量降至19.2戈瑞之前。此外，10例患者在治疗后4至34个月因残留畸形发生出血。最初有癫痫发作和头痛的35例患者中，63%的患者癫痫发作减轻，40例患者中，68%的患者头痛减轻。
鉴于这些难以触及病变的自然病程以及手术的高风险，我们得出结论，重带电粒子辐射是治疗有症状、手术难以触及的颅内动静脉畸形的有效疗法。目前的治疗方法有两个缺点：血管病变完全闭塞前的潜伏期延长，以及发生严重神经并发症的风险较小。
