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Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks

Authors Hasegawa H, Yamamoto M, Shin M, Barfod BE

Received 6 August 2019

Accepted for publication 22 October 2019

Published 18 November 2019 Volume 2019:15 Pages 1351—1367


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Garry Walsh

Hirotaka Hasegawa,1 Masaaki Yamamoto,2 Masahiro Shin,1 Bierta E Barfod2

1Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan; 2Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan

Correspondence: Masaaki Yamamoto
Katsuta Hospital Mito GammaHouse, 5125-2 Nakane, Hitachi-Naka, Ibaraki 312-0011, Japan
Tel +81-29-271-0011
Fax +81-29-274-1475

Abstract: Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.

Keywords: arteriovenous malformation, cavernous malformation, dural arteriovenous fistula, gamma knife radiosurgery, stereotactic radiosurgery

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