Next is Dr. Jacobs talking about defining long-term clinical outcomes and risks of SRS for brainstem cavernous malformations. My name is Rachel Jacobs. I'm from the University of Pittsburgh School of Medicine, and I'm here to talk about the clinical outcomes and re-bleed risk after stereotactic radiosurgery for brainstem cavernous malformations. The role of stereotactic radiosurgery for high-surgical-risk brainstem cavernous malformations has remained controversial. We compared re-bleed rates and outcomes in cavernous malformation patients with both intrinsic and exophytic cavernous malformations presenting to appeal surface. Our cohort included patients who received gamma knife stereotactic radiosurgery between 1988 and 2016. This included 76 patients with solitary symptomatic brainstem cavernous malformations, 49 of which were intrinsic and 27 considered exophytic as they presented to appeal or ependymal surface. 91% of these patients had suffered at least two symptomatic hemorrhages, and 14 patients had undergone prior microsurgical resection before radiosurgery. Fifteen patients had re-bleeds after stereotactic radiosurgery, and we constructed Kaplan-Meier curves for hemorrhage-free survival and symptom deterioration rate for cranial nerve symptoms and signs. Our hemorrhage-free survival rates were 92% at one year, 87% at three years, and 85% at five years. And we confirmed a significant reduction in the annual hemorrhage rate from 31% to 4% during the first two years after stereotactic radiosurgery, and further reduced after two years had elapsed to 2%. We looked at the factors associated with the higher rate of hemorrhage as well as the factors associated with an increased risk of symptom deterioration using univariate and multivariate analyses. On univariate analysis, large target volume, prior surgical resection, and number of hemorrhages before stereotactic radiosurgery were associated with an increased risk of symptom deterioration as well as a higher rate of hemorrhage. And on multivariate analysis, higher number of prior hemorrhages before stereotactic radiosurgery were associated with both a higher rate of hemorrhage as well as an increased risk of symptom deterioration. Our analysis and results were stratified by intrinsic versus exophytic in those presenting to appeal ependymal surface, and we found no difference in re-bleed rate or symptom deterioration risk between intrinsic or exophytic cavernous malformations. And you can also see a non-significant trend for lower hemorrhage rates for intrinsic and exophytic lesions post-stereotactic radiosurgery with 6% and 3%. In conclusion, we have a mixed cohort of potentially operable exophytic cavernous malformation lesions and more definitively inoperable intrinsic lesions. The unique information provided here, it proves useful information for the surgeon that's faced with an intrinsic cavernous malformation that's located in the middle of the pons. And our data can influence practitioners that patients with brainstem cavernous malformations with multiple bleeds should undergo stereotactic radiosurgery early rather than observation until the hemorrhage presents to a brainstem. Thank you.

Dr. Rachel Jacobs

University of Pittsburgh School of Medicine

stereotactic radiosurgery

brainstem cavernous malformations

long-term clinical outcomes