A Stereotactic Radiosurgical Method and Use of Gamma-Knife in Treatment of Cerebral AVM

V.I. Tsimbalyuk, O.A. Tsimeiko, K.R. Kostyuk

Romodanov Institute of Neurosurgery Ukrainian Academy of Medical Science, Kiev, the Ukraine

 

One of the prospective methods of treatment in neurosurgery is stereotactic radiosurgical operations with use of the Gamma-knife (GK). This technology permits to perform interventions on deep-lying cerebral structures without classic trephination. This method is based on transmission of gamma waves of low intensity from the 201 radioactive source, known as cobalt 60. These waves are concentrated in a predetermined cerebral target. The gamma waves pass through anatomic structures of a head and brain, as well as cerebral structures, adjacent to a pathologic focus, without damaging them. GK can effect deep-lying cerebral structures, which are difficult-of-access even in use of up-to-date microsurgical instruments. Any other attempts to approach them can lead to considerable trauma of vital or eloquent cerebral areas. Stereotactic radiosurgical operations are widely used for treatment of patients with craniocerebral lesions and cases with some types of cerebrovascular pathology. Besides, it gives good results in trigeminal neuralgia, epilepsy and other CNS diseases. Limitations of such operations lie in the following fact: they are effective only in some types of cerebral lesions and when a focus size doe not exceed 3 cm in diameter.

The Kievsky Institute of Neurosurgery and the Leksellovsky Center of Gamma-Knife Surgery (Hospital in Gomolka, Prague) developed a joint program on carrying out radiosurgical treatment of the Ukrainian citizens some years ago. A number of cases with AVM, operated with the help of radiosurgery and the Gamma-knife in 2000-2004, was equal to 28. Their age varied from 4 up to 39 years. There were 19 females, 8 males and 20 children under 16. Subtentorial and supratentorial AVM were watched in 2 and 26 patients respectively. Hemorrhage was the first manifestation of the disease in the majority of cases. AVM manifested itself in epileptic seizures in 2 patients (females of 34 and 36 years old). AVM volume varied from 590 mm3 up to 31300 mm3 (2820 mm3 on the average). Radiosurgery was preceded by partial endovascular exclusion of AVM with a glue composition in 12 cases (2 of them were subject to it two times). A mean total irradiation dose was 43 Gy. Repeated radiosurgical interventions were performed in 2 cases in 8 and 17 months. These double-stage operations were planned at the very beginning of treatment due to a big size of AVM.

Radiosurgical treatment was tolerated satisfactorily by all the patients. There were no serious complications in an early postoperative period. A period of stay in hospital was 3 days. One case developed repeated subarachnoid hemorrhage three months after GK use. Control angiographic examination was carried out in 5 cases in 12-24 months. Complete exclusion of AVM from blood flow was watched in all the patients.

Thus, stereotactic radiosurgery with the Gamma-knife use is an effective, safe and prospective method of treatment of some cerebral AVM. Such operations are a method of choice in AVM, located in deep-lying or eloquent areas of the brain, when open microsurgical and endovascular interventions are either impossible or connected with a high risk of complications development. GK should find a wider use in clinical practice.