J Cerebrovasc Endovasc Neurosurg.  2015 Mar;17(1):36-42. 10.7461/jcen.2015.17.1.36.

Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause

• Kim DH
• Kang DH
• Park J
• Hwang JH
• Park SH
• Son WS

• KMID: 1963148
• DOI: http://doi.org/10.7461/jcen.2015.17.1.36

Abstract

Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.

Keyword

Arteriovenous malformation; Cerebral infarction; Gamma-knife radiosurgery; Radiation-induced vasculopathy

MeSH Terms

Arteries*
Arteriovenous Malformations*
Cerebral Infarction
Intracranial Arteriovenous Malformations
Middle Cerebral Artery
Radiosurgery*
Stroke*

Figure

• 

  Fig. 1 Magnetic resonance imaging and cerebral angiography shows a Spetzler-Martin grade 2 arteriovenous malformation (AVM) located in the right deep temporal lobe, adjacent to the basal ganglia (A and B). This AVM is supplied by a perforator of A1 segment and M1 segment, drained by the basal vein of Rosenthal (C and D).

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  Fig. 2 Gamma-knife radiosurgery was performed with a 9.6 mL lesion volume and a 20 Gy marginal dose.

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  Fig. 3 Seventeen months after gamma-knife radiosurgery. magnetic resonance imaging showed acute cerebral infarction at the right basal ganglia.

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  Fig. 4 At 2 years after gamma-knife radiosurgery, follow-up angiography showed complete obliteration of the arteriovenous malformation (A and B).

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  Fig. 5 Baseline magnetic resonance imaging showed an arteriovenous malformation (AVM) at the right Basal ganglia (A and B). This AVM is supplied by middle cerebral artery M1 segment, drained by an internal cerebral vein (C and D).

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  Fig. 6 Gamma-knife radiosurgery was performed with a 2.4 mL lesion volume and an 18 Gy marginal dose.

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  Fig. 7 Eleven months after gamma-knife radiosurgery. MRI showed an acute cerebral infarction on the right putamen (A and B).

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  Fig. 8 At the 3-year follow-up angiography, nearly total occlusion of the arteriovenous malformation was observed.

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