用于颅内海绵状血管畸形的伽玛刀®立体定向放射外科治疗

Gamma Knife® stereotactic radiosurgery for intracranial cavernous malformations.

作者信息

Shanker Mihir D, Webber Rebecca, Pinkham Mark B, Huo Michael, Olson Sarah, Hall Bruce, Jayalath Rumal, Watkins Trevor, Foote Matthew C

机构信息

Garry Reichart Gamma Knife Fellow, PA Research Foundation, Princess Alexandra Hospital, Brisbane, QLD, Australia; Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.

Gamma Knife Centre of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.

出版信息

J Clin Neurosci. 2022 Dec;106:96-102. doi: 10.1016/j.jocn.2022.10.015. Epub 2022 Oct 20.

DOI:10.1016/j.jocn.2022.10.015

PMID:36274300

Abstract

INTRODUCTION

Gamma Knife® stereotactic radiosurgery (GKSRS) is a non-invasive alternative to surgical resection for cerebral cavernous malformations (CCMs), especially in eloquent locations.

METHODOLOGY

A retrospective review was performed on an Australian cohort of patients receiving GKSRS for CCMs at a single institution. All patients exhibited symptoms and/or radiological evidence of haemorrhage before therapy. The minimum follow-up was 1-year post-GKSRS. McNemar's test was used for differences in matched-pair outcomes pre- and post-GKSRS with an α = 0.05. A systematic review and meta-analysis was additionally performed to synthesise the current published evidence on the clinical efficacy of stereotactic radiosurgery in reducing haemorrhage risk in CCMs using a DerSimonian and Laird random effects model.

RESULTS

Thirty-five patients (39 cavernomas) underwent GKSRS. 87.2 % of patients had evidence of at least one haemorrhage before GKSRS and the remainder exhibited seizures. The median dose was 12.5 Gy in a single fraction (IQR 12-13). The median follow-up duration from GKSRS was 809 days (IQR 536-960). There was a significant reduction in matched annual bleed rate from pre-GKSRS (52.1 %) compared to after SRS (12.3 %) (p < 0.001) [OR = 0.07, 95 % 0.008-0.283] There was no statistically significant difference in seizure incidence pre- (30.7 %) versus post-GKSRS (17.9 %) (p = 0.13) [OR = 0.167, 95 %CI 0.004-1.37]. One patient (3 %) with a brainstem lesion experienced long-term treatment-related oedema with persistent ipsilateral weakness and tremors. On meta-analysis of 25 pooled studies, radiosurgery for the treatment of CCMs was associated with a statistically significantly relative risk (RR) reduction in haemorrhage events [random effects RR 0.12 (95 % CI 0.074-0.198), p < 0.001)], with most of the proportionate risk reduction occurring in the initial 2 years following SRS.

CONCLUSION

GKSRS significantly reduces the annual rate of haemorrhage for intracranial cavernomas in this cohort and on meta-analysis, particularly in the first 2 years following treatment. The overall risk of treatment-related morbidity is low.

摘要

引言

伽玛刀立体定向放射外科治疗（GKSRS）是一种用于治疗脑海绵状血管畸形（CCM）的非侵入性手术切除替代方法，尤其适用于功能区病变。

方法

对澳大利亚一家机构接受GKSRS治疗CCM的患者队列进行回顾性研究。所有患者在治疗前均有出血症状和/或影像学证据。GKSRS术后最短随访时间为1年。采用McNemar检验比较GKSRS术前和术后配对结果的差异，α=0.05。此外，还进行了系统评价和荟萃分析，以综合目前已发表的关于立体定向放射外科治疗降低CCM出血风险的临床疗效的证据，采用DerSimonian和Laird随机效应模型。

结果

35例患者（39个海绵状血管瘤）接受了GKSRS治疗。87.2%的患者在GKSRS术前有至少一次出血证据，其余患者有癫痫发作。单次分割的中位剂量为12.5 Gy（四分位间距12-13）。GKSRS术后的中位随访时间为809天（四分位间距536-960）。与GKSRS术前（52.1%）相比，立体定向放射外科治疗（SRS）术后配对年出血率显著降低（12.3%）（p<0.001）[OR=0.07，95%CI 0.008-0.283]。癫痫发作发生率在GKSRS术前（30.7%）和术后（17.9%）无统计学显著差异（p=0.13）[OR=0.167，95%CI 0.004-1.37]。1例（3%）脑干病变患者出现长期治疗相关水肿，伴有持续性同侧无力和震颤。对25项汇总研究的荟萃分析表明，放射外科治疗CCM与出血事件的相对风险（RR）在统计学上显著降低相关[随机效应RR 0.12（95%CI 0.074-0.198），p<0.001]，大部分风险降低比例发生在SRS后的最初2年。