Gamma Knife Neurosurgery (eBook)

Jeremy C. Ganz, born in 1943 in the UK, he is a Cambridge University graduate. He moved to Norway in 1976 and became a staff neurosurgeon in Bergen from 1979. He became director of the world’s 5th Gamma Knife in 1988. From 1993 he taught Gamma Knife radiosurgery to new users in over 75 centres round the world. He built up a Gamma Knife Centre in Cairo between 2001 and 2007 then returning to the Bergen Gamma Knife team.

Gamma Knife Neurosurgery 3
Foreword 7
Preface 9
Acknowledgements 11
Contents 13
Part I: Background Principles and Technical Development 23
Chapter 1: Introduction and the Nature of Radiosurgery 24
Definitions of Radiosurgery 26
Consequences of Changing Definitions of Radiosurgery 27
Non-neurosurgical Treatments and Fractionation 27
Microsurgery, Gamma Knife Surgery and Their Relationship to Each Other 28
Aims of This Book 29
References 29
Chapter 2: Principles of Stereotaxy 30
Introduction 30
Principles 31
The Leksell System 32
Target Identification 32
Newer Localization Methods 34
Modern Indications for Stereotaxy 36
Conclusion 36
References 37
Chapter 3: Ionising Radiation and Its Effects on Living Tissue 38
Introduction 38
Radiophysics 38
Basic Concepts 38
Units 40
Electromagnetic Radiation 42
Particle Radiation 43
The Effect of Electromagnetic Radiation on Matter at the Atomic Level 44
The Photoelectric Effect 44
Compton Scattering 44
Pair Production 45
The Effect of Charged Particles on Matter 46
Consequences of Radiation Induced Damage on Biological Tissue 49
Early Effects 49
Radiation Injuries to Nucleic Acid Molecules 50
Response to Radiation Damage of DNA Molecules 50
Checkpoints in the Cell Cycle 51
Cell Death 51
DNA Repair 52
References 52
Chapter 4: Biological Effects of Ionising Radiation 53
Introduction 53
Cell Survival Studies [1] 53
The Linear Quadratic Equation [2-4] 54
Mechanisms of Cellular Repair [1] 55
Lethal-Potentially-Lethal model 55
Saturation Repair Model 57
Different Factors Affecting the Effects of Radiation 58
Biological Factors 58
The Cell Cycle [5] 58
Oxygenation [1] 59
Radiation Factors 60
Fractionation and Fraction Size [2, 4] 60
Time Between Fractions 61
Dose 61
Dose Homogeneity 62
Dose Volume 62
Dose Rate 63
Clinical Radiobiological Correlates 63
The Fate of the Normal Tissue 63
Hierarchical Tissues (H-Type) 63
Flexible Tissues (F-Type) 64
Tissue Architecture 64
Cell Cycle Time (Tc) and Tumour Doubling Time (Td) 64
The Fate of Irradiated Tumour Cells 64
The Radiosensitivity of the Tumour 65
The Volume of the Tumour 65
Accelerated Repopulation 65
The Tumour Bed Effect 65
The Hypoxic Reaction 66
Reoxygenation 66
References 66
Chapter 5: Ionising Radiation and Clinical Practice 67
Introduction 67
General Clinico/Pathological Principles 67
The Therapeutic Index 67
Time Dose Relationships 68
Early and Late Reactions 69
The Linear Quadratic Equation and Early and Late Complications 69
Early Reactions 69
Late Reactions 70
Adverse Radiation Effects in the Brain 70
Severe Somatic Adverse Radiation Effects in the Brain 70
Less Severe Somatic Adverse Radiation Effects in the Brain After Gamma Knife Treatment 71
Genetic Adverse Effects Following Brain Irradiation 71
References 72
Chapter 6: Gamma Knife Development from 1967 to 2010 73
General Information 73
Introduction 73
Preparatory Basic Research 73
The First Patients 76
The First Gamma Unit 76
Requirements 76
Early Experience 78
The Second Gamma Unit 79
The Third Gamma Unit (Gamma Knives U and B) 80
Fixation of the Patient to the Gamma Knife 80
Automatic Positioning 82
Gamma Knife Perfexion 83
Introduction 83
Design DifferencesGamma Knife Development Gamma Knife Perfexion Design Difference 84
Chapter 7: Radiophysics, Radiobiology and the Gamma Knife 87
Introduction 87
Radiophysics and the Gamma Knife 87
Energy 87
Radiobiology and the Gamma Knife 88
Factors Affecting Cell SurvivalGamma Knife and Basic Science Factors Affecting Cell Survival 88
Dose 88
Dose Rate 88
Dose Volume 89
Dose Homogeneity 90
Delayed Radiation Damage of Nervous Tissue and the Gamma Knife 90
Radiation Tolerance of the CNS 90
Dose Latency Relationships 91
CNS Radiation Tolerance and Fractionation 92
Tumour Tissue and the Gamma Knife 93
Radiobiological Correlates with Single Session Radiosurgery 94
Relevance of the Linear Quadratic Equation 94
Relevance of Fractionation 95
Conclusion 96
References 96
Chapter 8: Preparation for Treatment Planning 98
Introduction 98
Frame Application: General Method for Gamma Knife C Models 98
Frame Placement in the Gamma Knife Helmet for Single Targets 99
Intracranial Extracerebral Solitary Targets: Frame Displacement 101
Pituitary Adenoma 101
Vestibular Schwannoma 101
Parasellar Meningioma 101
Intracranial Extracerebral Solitary Targets: Frame Rotation 103
Lateral Sphenoidal Ridge Meningioma 103
Glomus Jugulare Tumour 103
Intracranial Intracerebral Multiple Targets 105
Intracranial Intracerebral Multiple Targets: Frame Displacement and Rotation 107
Frame Application: General Method for Gamma Knife Perfexion 108
Frame Application 108
The Frame CapFrame Application Perfextioin The Frame Cap 108
Imaging: MRI 109
Sources of Distortion on MR Images 109
Imaging: Angiogram 111
DSA Images 111
References 113
Chapter 9: Dose Plan Indices 118
Dose-Plan Finalisation 118
Conformity Index: RTOG PITV Index [1] 118
Target Volume Ratio (TVR) [2] 118
Paddick Conformity Index (PCI) [1] 119
Selectivity [3] 119
Gradient Index 120
Comment on the Use of Indices 120
References 121
Part II: The Patient’s Experience 122
Chapter 10: Gamma Knife Surgery and Computer Networks 123
Introduction 123
The Effect of Computer Networks on the Physician 123
The Effect of the Computer Networks on the Patient 125
Computer Networks and Medical Ethics 125
Conclusion 126
References 127
Chapter 11: Aims of Gamma Knife Surgery 128
Introduction 128
What We Want to Do and What We Can Do 128
What Is in the Patient´s Best Interest? 129
Conclusion 130
References 130
Chapter 12: Principles of Information and Follow Up 131
Introduction: The Processes of Referral 131
Information After Acceptance 132
The Nature of the TechniqueAcceptance Information The Nature of the Technique 132
The Safety of the TechniqueAcceptance InformationThe Safety of the Technique 132
The Degree of Disruption to the Patient´s LifeAcceptance Information The Degree of Disruption to the Patient`s Life 132
The WaitingAcceptance Information The Waiting 133
Information on Admission to Hospital 133
The Brochure 133
The Day Before 134
The Day of Treatment 134
Follow-Up 135
Benign Tumours 135
Malignant Gliomas 135
Metastases 135
AVMs 135
Other Follow Up Measurements 136
Conclusion 136
Part III: The Gamma Knife and Specific Diseases:Tumours 137
Chapter 13: Vestibular Schwannomas 138
Unilateral Vestibular Schwannomas: History and Microsurgery 138
Introduction 138
Debates About Function After Treatment 139
Facial Nerve Function 139
Preservation of Hearing After Surgery 140
Unilateral Vestibular Schwannomas: Gamma Knife Neurosurgery 141
Gamma Knife and Vestibular Schwannomas 141
The Early DaysVestibular Schwannomas Gamma Knife The early days 142
Current Gamma Knife Treatment 142
Information 143
Preparation for Treatment 143
Imaging 143
Dose Planning 143
Follow Up 144
Tumour Control 144
Possible Complications and Problems 145
Facial Palsy 145
Trigeminal Dysfunction 146
Hearing Loss 146
Cochlear Nuclei 147
Cochlea 148
The Intrameatal Tumour Volume 148
Other Symptomatic Problems and Occasional Complications 148
Quality of Life 149
Gamma Knife or Microsurgery 150
Intracanalicular Vestibular Schwannomas 150
Large Vestibular Schwannomas 151
Patients with Bilateral Tumours 152
Neurofibromatosis 2 152
Addendum Related to Dosimetry 153
References 153
Chapter 14: Meningiomas 159
Introduction 159
Natural History of Meningiomas 160
Contribution of Computerised Imaging 160
Factors Concerning Who When and How to Treat Intracranial Meningiomas 161
Tumour Size 161
Patient Age and General Health 161
Decision Making in the Treatment of Meningiomas: To Treat or Not to Treat 161
Radicality of Surgery 162
Tumour Location and Its Effect on Choice of Treatment 163
Changing Technology and the Effect on Surgical Mortality 163
The Morbidity and Mortality of Microsurgery and GKNS 164
Other Factors that Are Relevant to the Choice of Treatment 164
Tumour Consistency 164
Tumour Vascularity 164
Peritumoral Oedema 164
WHO Grade 168
Multiple Tumours 168
Results of Microsurgery Compared with GKNS 168
How to Improve the Results 169
Making the Surgery Easier 169
Improving the Results of GKNS 170
Dose and Complications 170
WHO Grade and Recurrence Rate 171
Maximising the Safe Tumour Control Rate 171
Minimising the Complication Rate 171
Non-basal Tumours 171
Vascular Injury 172
Cranial Nerve Injury 173
Comments on Fractionation 174
Optic Nerve Sheath Meningiomas 174
Malignant Change 175
Conclusion 175
References 176
Chapter 15: Gamma Knife for Cerebral Metastases 183
Preamble About Problems 183
Concepts Scales and Parameters for Evidence Based Treatment 184
Phases of Clinical Trials (Institute of Cancer Research) 184
Phase I 184
Phase II 184
Phase III 184
Ranking of Evidence 185
Karnowsky Score 185
Parameters Concerned in the Management of BMs are Listed Below 186
Recursive Partition Analysis (RPA) of the RTOG 187
Score Index for Stereotactic Radiosurgery for Brain Metastases (SIR) 187
Basic Score for Brain Metastases (BS-BM) 188
Graded Prognostic Assessment (GPA) 188
Background 189
The Size of the Problem 189
The Evolution of Imaging Techniques 189
Development of Treatment Methods 189
The Introduction of Radiosurgery 190
Stockholm Studies 190
Boston Studies 191
End Point of Treatment 191
Local Tumour ControlCerebral Metastases End Point of Treatment Local Tumour Control 191
Findings of Level 1 Evidence Studies 192
Patient SurvivalCerebral Metastases End Point of Treatment Patient Survival 192
Findings of Level 1 Evidence Studies 192
Treatment-Related Complications Principles 193
Acute Adverse Effects After WBRT 193
Adverse Radiation Effects and Radionecrosis 193
Radiation Induced Dementia and Leukoencephalopathy 194
Treatment Strategies for BMs 195
Should Up Front WBRT Be Used in All Patients? 195
The Arguments for and Against Using WBRT 195
Additional Considerations 196
What About Salvage Treatments? 197
Advice to Gamma Knife Users About WBRT 197
The Effect of Dose on Results and Complications 198
Practical Treatment 199
Referral 199
Acceptance 199
Admission 199
Day of Treatment 200
Frame Application 200
Perfexion 200
Gamma Knife 4C 200
Imaging 200
Dose Plan 200
Follow up 201
Routines 201
Complications 201
Conclusions 203
References 203
Chapter 16: Intraparenchymal Intrinsic Brain Tumours 211
Introduction 211
Gliomas 212
Classification 212
Low Grade Gliomas 212
Grade 1: Pilocytic Astrocytomas 212
Grade 2: Diffuse Astrocytomas 212
Grade 2: OligodendrogliomasGliomas Low GradeGrade 2 - Oligodendrogliomas 213
High Grade Gliomas 213
Grade 3: Anaplastic Astrocytomas 213
Grade 4: Glioblastoma Multiforme 213
Gamma Knife Treatment of Glioma 213
Low Grade Gliomas 213
Grade 1: Pilocytic Astrocytomas 214
Grade 2: Diffuse Astrocytomas 217
Grade 2: OligodendrogliomasGliomas Low GradeGrade 2 - Oligodendrogliomas 219
Follow up of Patients with Gliomas Grades 1 and 2 219
High Grade Gliomas 219
Special Gliomas 220
Anterior Optic Pathway Gliomas 220
Brain Stem Gliomas 220
Gliomas Conclusions 221
Other Tumours Arising from Cerebral Tissue 221
Choroid Plexus Papillomas 221
Ependymomas 221
Medulloblastomas 222
Pineal Region Tumours 222
Tumours Arising from the Pineal Gland 223
Type of Biopsy 223
GKNS and Pineal Parenchymal Tumours 224
Reviews of Pineal Parenchymal Tumours 224
Hydrocephalus 225
Germ Cell Tumours 225
Tumours Arising in the Pineal Region 225
Concluding Remarks About Pineal Region Tumours 226
Neurocytoma 226
Haemangioblastoma 226
References 227
Chapter 17: Tumours of the Pituitary Region 232
Pituitary Adenomas 232
Introduction and a Little Surgical History 232
GKNS Reminiscences 233
Some General Principles 234
Primary or Secondary Treatment Option 234
Comparison with Fractionated External Beam Radiotherapy 234
Visual Fields Complications 234
Tumour Location 235
Radiation Induced Hormone Deficiencies After GKNS 235
Radiation Induced Carotid Ischaemia 235
Prescription Dose 235
Variation in Reporting 236
Cushing´s Disease Pituitary Adenomas Endocrinopathy Cushing´s disease 236
Aims of Treatment 236
AcromegalyPituitary Adenomas Endocrinopathy Acromegaly 237
ProlactinomasPituitary Adenomas Endocrinopathy Prolactinomas 239
Results with MicroprolactinomasPituitary Adenomas EndocrinopathyResults with microprolactinomas 239
Macroadenomas 240
Nelson´s Syndrome 241
Craniopharyngiomas 242
Introduction 242
Case Selection 243
Results of Treatment 244
Conclusion 244
References 245
Chapter 18: Less Common Skull Base Tumours 251
Introduction 251
Benign Skull Base Tumours 251
Non-vestibular SchwannomasSkull Base Tumours Benign Non Vestibular Schwannomas 251
Trigeminal SchwannomaSkull Base Tumours BenignTrigeminal Schwannoma 251
Jugular Foramen SchwannomaSkull Base Tumours BenignJugular Foramen Schwannoma 252
Facial SchwannomaSkull Base Tumours BenignFacial Schwannoma 253
Schwannomas of the Nerves Controlling Ocular MovementSkull Base Tumours BenignSchwannomas of the nerves controlling ocular mov. 254
Glomus Jugulare TumorSkull Base Tumours BenignGlomus Jugulare Tumor 254
Malignant Skull Base Tumours 257
Adenoid Cystic CarcinomaSkull Base Tumours MalignantAdenoid Cystic Carcinoma 257
Chondrosarcomas and ChordomasSkull Base Tumours MalignantChondrosarcomas and Chordomas 258
NeuroblastomaSkull Base Tumours Malignant Neuroblastoma 259
List of Diagnoses Limited to Case Reports 260
References 260
Part IV: The Gamma Knife and Specific Diseases: Vascular Diseases 264
Chapter 19: Gamma Knife for Cerebral Vascular Anomalies 265
Introduction 265
Preamble About Principles 265
Nature of the Lesion 265
General Principles of Treatment 266
Sources of Practical Difficulty During TreatmentAVM Sources of Practical Difficulty during Treatment 267
Anatomical VariationAVM Sources of Practical Difficulty during Treatment Anatomical Variation 267
Size AVM Sources of Practical Difficulty during Treatment Anato 267
Vascular SupplyAVM Sources of Practical Difficulty during Treatment< Terti
LocationAVM Sources of Practical Difficulty during Treatment An 267
Clinical PictureAVM Sources of Practical Difficulty during Treatment Clinical Picture 267
Natural HistoryAVM Sources of Practical Difficulty during Treatment Natural History 268
The Development of Therapeutic Technology 268
Principles of Gamma Knife Treatment 269
Early Days 269
Obliteration 270
The Obliteration RateAVM Obliteration Obliteration Rate 270
Attempts to Predict Obliteration RatesAVM Obliteration Obliteration Rate Attempts to Predict Obliteration Rates 271
Prescription DosexVolumex1/3AVM Obliteration Obliteration Rate Attempts to Predict Obliteration Rates Prescription Dose x Volu. 271
Attempts to Predict and Manage Complication RatesAVM Complications Attempts to Predict and Manage Complication Rates 272
Re-bleedingAVM Complications Re-bleeding 272
Adverse Radiation Effects (AREs)AVM Complications Adverse Radiation Effects (ARE) 273
Ways of Calculating the Risk of Complications: Post Treatment AssessmentsAVM Complications Risk of Complications - Post Treatm. 274
Paired Sigmoid CurvesAVM Complications Risk of Complications - Post Treatment Assessments Paired Sigmoid Curves 274
The Integrated Logistic FormulaAVM Complications Risk of Complications - Post Treatment Assessments The Integrated Logistic Fo. 274
The Linear Form 275
The Exponential Form 275
The Total 12Gy Volume [93], PRI PIE and SPIE 276
Plotting Risk of Symptomatic Radionecrosis for Increasing Total 12Gy Volume 277
Total 12Gy Volume and Normal Tissue 12Gy VolumeAVM Complications Risk of Complications - Post Treatment Assessments Total 12 G. 278
The Integral DoseAVM Complications Risk of Complications - Post Treatment Assessments The Integral Dose 278
Ways of Calculating the Risk of Complications: Pre-treatment AssessmentsAVM Complications Risk of Complications - Pre Treatmen. 279
Spetzler-Martin GradeAVM Complications Risk of Complications - Pre Treatment Assessments Spetzler-Martin Grade [99] 279
Radiosurgery Based Grading SystemAVM Complications Risk of Complications - Pre Treatment Assessments Radiosurgery Based Gradin. 280
Modified Rankin Score 281
How GKNS Works on AVMs: Changes in Arteries Following Radiation 281
Patient Assessment for Gamma Knife Surgery 282
Informing the Patient (Family) 283
Day of Treatment 284
Frame 284
Imaging 284
Follow Up 284
Epilepsy 286
Engels Classification [114] 286
Treatment Failure 287
Repeated Treatment 288
Large AVMs 288
Combined Treatments 289
Endovascular Treatment 290
Gamma Knife for Cerebral Cavernous Malformations 291
Natural History 292
Clinical Material 292
What is a Bleed? 292
Location 292
Bleeding Rate and Re-bleeding Rate 293
Changes in Size 293
Bleeding and Non-bleeding Lesions 293
Clustering of Bleeding 293
Epilepsy 294
Factors Affecting Outcome 294
Post Irradiation CMs 294
Summary of Relevant Natural History 294
Therapy of CMs 295
Treatment of CM Associated Epilepsy 296
Treatment of CM Associated with Haemorrhage 296
More Dangerous CMs 297
Conclusions About CMs 298
Cairo Patients 299
Gamma Knife for Dural Arteriovenous Fistulae 300
Cerebral Developmental Venous Anomalies 300
References 301
Part V: The Gamma Knife and Specific Diseases Functional Indications 310
Chapter 20: Trigeminal Neuralgia 311
Introduction 311
Classical Trigeminal Neuralgia [1] 311
DescriptionTrigeminal Neuralgia Description 311
Diagnostic CriteriaTrigeminal Neuralgia Diagnostic criteria 312
Symptomatic Trigeminal Neuralgia 312
DescriptionTrigeminal Neuralgia Description 312
Pathology and Pathophysiology 312
Histopathology 312
Secondary Factors 313
Trigeminal Nerve Compression 313
Contribution of Microvascular Compression (MVC) as an Aetiological Factor: Arguments for and Against 314
The Part of the Trigeminal Root Related to a Blood VesselTrigeminal Neuralgia MVC Location of pressure 315
The Nature of the Relationship Between the Blood Vessel and the Nerve 316
The Question of VeinsTrigeminal Neuralgia MVC The question of veins 317
Treatment Principles 317
A Vital Principle 317
Aim of Treatment 317
Medical Treatment 318
The Development of Interventional Treatments 318
Classification 318
Failure of Medical Treatment 318
Effects of Open Surgery 319
Early Attempts 319
Rhizotomy 319
Taarnhøj´s Operation 321
Recording of Results 321
BNI Pain Intensity Scale [40] 321
MVD 321
Introduction 321
Success Rate 322
ComplicationsTrigeminal Neuralgia MVD Complications 322
Alcohol or Phenol Injections into a Peripheral Trigeminal Branch or the Gasserian Ganglion 322
Radiofrequency Lesions 323
Glycerol Injection 324
Balloon Compression 325
Gamma Knife Treatment 325
Introduction 325
The Mechanism by Which GKNS Can Affect Trigeminal Neuralgia 326
Development of Radiosurgery for Use with Trigeminal Neuralgia 327
GKNS Technique in the Treatment of Trigeminal Neuralgia 328
Frame ApplicationTrigeminal NeuralgiaGKNS Frame Application 328
ImagingTrigeminal NeuralgiaGKNS Imaging 328
TechniqueTrigeminal Neuralgia GKNS Imaging Technique 328
FindingsTrigmineal Neuralgia GKNS Imaging Findings 328
Treatment TechniqueTrigeminal NeuralgiaGKNS Treatment Technique 328
Target LocationTrigeminal Neuralgia GKNS Target Location 328
DoseTrigeminal Neuralgia GKNS Dose 329
The Number of Shots and the Use of PlugsTrigeminal Neuralgia GKNS The Number of Shots and the use of Plugs 330
Success Rates and Recurrence 330
Trigeminal DeficitTrigeminal Neuralgia GKNSTrigeminal Deficit 331
MVC and GKNS 331
MVD After Failed GKNS 331
Secondary Trigeminal Neuralgia and Atypical Facial Pain 331
Conclusions 332
The Nature of GKNS Treatment 332
MVC and MVD 332
Considerations About the Sequence of Interventional Treatments for Trigeminal Neuralgia 333
References 333
Chapter 21: Diverse Functional Indications 341
Introduction 341
Parkinson´s Disease and Essential TremorFunctional Indications Diverse Parkinson´s disease Functional Indications Diverse Esse. 341
EpilepsyFunctional Indications Diverse Epilepsy 343
Epilepsy Associated with Treatment Aimed Primarily at a Visible LesionFunctional Indications Diverse Epilepsy Visible Lesion 344
Epilepsy Where the Epilepsy is the Reason for TreatmentFunctional Indications Diverse Epilepsy epilepsy is the reason for trea. 344
Mesial Temporal Lobe Epilepsy is the Reason for TreatmentFunctional Indications Diverse Epilepsy Mesial Temporal Lobe Epilepsy 344
Hypothalamic Hamartomas and Gelastic EpilepsyFunctional Indications Diverse Epilepsy Mesial Hypothalamic Hamartoma 347
Pain 349
Intracranial Pain Syndromes 349
Nerve Related Pain SyndromesPain Intracranial Pain syndromes Nerve related pain syndromes 349
Thalamic Pain 349
Extracranial Pain Syndromes 349
Psychosurgery 350
References 350
Part VI: The Gamma Knife and Specific Diseases:Less Common Indications 355
Chapter 22: Rare Tumours and Other Lesions 356
Introduction 356
Hemangiopericytoma 356
Lymphoma 357
Rare Conditions Where the Information Is Based on Case Reports 358
References 358
Chapter 23: Orbital Indications 360
Introduction 360
Uveal Melanomas Background Information 360
Treatment Technique 361
Case Selection 362
Results in Terms of Local Control 362
ComplicationsUveal Melanoma GKNS Complications 363
Conclusion 364
Choroidal Haemangioma 364
Glaucoma 365
Optic Nerve Gliomas and Optic Nerve Sheath Meningiomas 365
Rare Conditions Where the Information is Based on Case Reports 365
References 366
Part VII:Conclusions 368
Chapter 24: Conclusion and Possible Future Trends 369
Introduction 369
The Responsible Physician 369
The Therapeutic Team 370
Team Members with Treatment Expertise Would Have to Include 370
Team Members Who Refer and Follow Up Might Include 370
Functions of the Team 371
Personal Radiosensitivity: A Concluding Remark 371
Appendix A: A Simple Unassisted Frame Application 372
Introduction 372
Frame Application 372
Completion 375
Index 376