Winter 2007

Case Study: Gamma Knife for AVM

Fifteen-year-old boy RA presented to a community hospital emergency room with a hemorrhage into a ventricle of the brain. Upon evaluation, imaging studies showed an arteriovenous malformation (AVM) deep in the brain. Such deep AVMs are challenging to treat.

Referral to UCSF

The community physician chose to refer the patient to UCSF Benioff Children's Hospital because he had had previous experience with UCSF neurologists and was aware of their extensive experience with AVMs.

Evaluation

Upon evaluation at UCSF by a multidisciplinary team of neurological surgeons, neurologists and radiologists, the patient demonstrated moderate disability from the brain hemorrhage and hydrocephalus. A ventriculoperitoneal shunt was placed to ameliorate hydrocephalic pressure. More detailed imaging studies were done at UCSF to obtain a higher-resolution picture of the AVM.

Typically, AVMs are treated through surgery or interventional radiology entailing either endovascular coiling or the placement of balloons to seal off the arteriovenous shunt. Neither option was satisfactory in this case. The AVM was located too deep in the brain to be easily accessible through surgery, and involved blood vessels that were too small to use coiling or balloons.

Treatment

The most appropriate treatment choice in this case was determined to be via the Gamma Knife, a multi-beam, calibrated radiosurgery technique that would destroy the inappropriate arteriovenous connections in the AVM. The preparation for treatment with the Gamma Knife required close cooperation between neurological surgeons, radiation oncologists, physicists and interventional radiologists. Extensive imaging was done to locate the AVM and carefully plan the radiosurgery with the Gamma Knife.

The patient was fitted with a stereotactic head frame in order to precisely deliver the planned radiation dosages. RA was treated a single time with the Gamma Knife, and the results were judged to be successful. RA was also treated at UCSF for disability caused by the initial hemorrhage.

Outcome

An MRI done one year after treatment and an angiogram done three years later showed normal blood circulation in the thalamic location previously occupied by the AVM. RA will have another angiogram in five years, but the expectation is that he is cured, and he has since returned to the life of a typical teenager.

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