title: Gamma Knife radiosurgery for brainstem cavernous malformations: should a patient wait for the rebleed?
abstract: BACKGROUND
  The effectiveness of stereotactic radiosurgery (SRS) for cavernous malformation (CM) has not been fully assessed. Consequently, observation is usually recommended when a bleeding CM is initially discovered. Recurrent bleeding occurs with CMs, and these repeat hemorrhages can result in additional morbidity.
  
  
  METHODS
  From 1992 to 2011, 49 patients with brainstem CMs were treated with Gamma Knife radiosurgery (GKS). We classified patients into two groups: Group A (n = 31), patients who underwent GKS for a CM following a single symptomatic bleed, and group B (n = 18), patients who underwent GKS for a CM following two or more symptomatic bleeds. The mean marginal dose of radiation was 13.1 Gy (range 9.0-16.8 Gy): 12.8 Gy in group A and 13.7 Gy in group B. The mean follow-up period was 64.0 months (range 1-171 months).
  
  
  RESULTS
  In group A, the annual hemorrhage rate (AHR) following GKS was 7.06 % within the first 2 years and 2.03 % after 2 years. In group B, four patients (22.2 %) developed new or worsening neurologic deterioration as a result of repeat hemorrhages. In group B, the AHR was 38.36 % prior to GKS, 9.84 % within the first two years, and 1.50 % after two years. There was no statistically significant difference in the AHRs at each follow-up period after GKS between the two groups. Adverse radiation effects (AREs) developed in a total of four patients (8.2 %); among them, one patient (2.0 %) developed a permanent case of diplopia. No mortality occurred in this series.
  
  
  CONCLUSIONS
  In this study, GKS was demonstrated to be a safe and effective alternative treatment for brain stem CMs that resulted in a reduction in the AHR. Consequently, we suggest that even CM patients who have suffered only a single bleed should not be contraindicated for SRS.
authors: Department of Neurosurgery, Kyung Hee University College of Medicine, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea.
authors: Sung Ho
authors: SH
authors: Lee
authors: Hyuk Jai
authors: HJ
authors: Choi
authors: Hee Sup
authors: HS
authors: Shin
authors: Seok Keun
authors: SK
authors: Choi
authors: In Ho
authors: IH
authors: Oh
authors: Young Jin
authors: YJ
authors: Lim
mesh_terms: D000328:Adult; D001933:Brain Stem / Q000601:surgery*; D004172:Diplopia / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D020786:Hemangioma, Cavernous, Central Nervous System / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome