All patients were treated on an Elekta Gamma Knife Perfexion (Elekta, Stockholm, Sweden). On the day of treatment, patients were imaged on a GE Discovery 750 or 750W 3T MRI system (GE Healthcare, Chicago, IL) for treatment planning. Imaging was performed with a Leksell Coordinate G Frame attached to the patient's skull. Treatment planning imaging consisted of an axial 3-dimensional fast spoiled gradient echo (FA = 12, TR = 6.65 ms, TE = 1.99 ms, N = 1) with a 0.9375 mm in-plane resolution and contiguous 1 mm slice thickness acquired after intravenous injection of MultiHance (gadobenate dimeglumine) at a dose of 0.1 mmol/kg.
Gamma knife perfexion
Manufactured by Elekta
Sourced in Sweden
The Gamma Knife Perfexion is a specialized medical device designed for stereotactic radiosurgery. It utilizes multiple focused beams of gamma radiation to precisely target and treat lesions, tumors, or other abnormalities in the brain. The Gamma Knife Perfexion provides highly accurate and focused radiation delivery to the target area.
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9 protocols using gamma knife perfexion
1
Gamma Knife MRI Treatment Planning
2
Stereotactic MRI-Guided Gamma Knife Radiosurgery
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As an inclusion criterion for this study, stereotactic MRI had been used for localization and target definition. Our standard protocol is to perform T2-weighted and proton density imaging using 1.5-mm slices, TE 80 msec, TR 3000 msec, 256 matrix, number of signal averages 1. Gam-maPlan (Elekta AB) was used for dose planning. Treatments were delivered with the Gamma Knife model RBS 5000 (Nucletec) until 2001, Gamma Knife Model C (Elekta AB) until 2011, and Gamma Knife Perfexion (Elekta AB) thereafter in the RHH and all with Perfexion in the TRC. The number of treated patients gradually increased from 3 in 1995 to an annual average of 20 more recently (Fig. 2A). The median time between presentation and treatment was 1 year (0.1-34 years). Cavernous malformations were defined within the hemosiderin ring and were treated after complete resolution of the last hematoma, and a median dose of 12-13 Gy (depending on location) was given to the 50% prescription isodose level, excluding coexisting developmental venous anomalies. 27 Our standard treatment protocol has not changed essentially since 1995, apart from a significant reduction in the prescription dose from 15 to 12 Gy after 2000 (p < 0.001; Table 2).
3
Comprehensive Radiation Oncology Facility
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The radiation oncology department at our institution includes 21 attending radiation oncologists who service our main site and 5 additional satellite locations. The main facility includes 7 linear accelerators with a dedicated MR simulator, a Gamma Knife Perfexion (Elekta, Stockholm, Sweden), a single-gantry proton therapy system (Mevion, Littleton, MA), a cobalt 60-based MR-IGRT system (ViewRay Inc., Oakwood Village, OH), and a full brachytherapy suite. A linear accelerator–based MR-IGRT system is currently under construction. Our satellite facilities have an additional 7 linear accelerators. In 2015, approximately 3,400 patients were treated with external beam radiation therapy at our facility.5 (link)
All patients included in this study were enrolled in an institutional review board–approved prospective registry, and informed written consent for treatment was obtained. Patients were divided into groups on the basis of the anatomical site of the malignancy and the treatment technique (stereotactic body radiation therapy [SBRT], adaptive, gating). Additionally, the clinical rationale with regard to the selection of MR-IGRT compared with conventional linac-based treatment was evaluated (ie, improved soft tissue imaging, cine gating on the basis of daily anatomy, and online/offline adaptation) when available.
All patients included in this study were enrolled in an institutional review board–approved prospective registry, and informed written consent for treatment was obtained. Patients were divided into groups on the basis of the anatomical site of the malignancy and the treatment technique (stereotactic body radiation therapy [SBRT], adaptive, gating). Additionally, the clinical rationale with regard to the selection of MR-IGRT compared with conventional linac-based treatment was evaluated (ie, improved soft tissue imaging, cine gating on the basis of daily anatomy, and online/offline adaptation) when available.
4
Gamma Knife Radiosurgery for AVM
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Until August 2012, radiosurgical treatment was performed using a Leksell Gamma Knife 4C with a 201-source cobalt-60 gamma unit. After August 2012, it replaced with a Gamma Knife Perfexion (Elekta AB, Sweden). All patients had undergone MRI after applying frames; non-contrast T1-weighted and T2-weighted images were taken at slice thickness of 1.5 mm.
The target was defined as the site of mixed signal change surrounded by an outer hemosiderin ring. Hematoma eccentric from the malformations was excluded. Radiotherapy dose plans were created with single or multiple isocenters (range 1-12), at the 50% isodose line in 62.2% of cases and a highly conformal dose distribution was achieved. The details of dose planning are summarized in Table I. After radiosurgery, all patients received 40 mg intravenous methylprednisolone and were discharged from hospital within a few hours.
The target was defined as the site of mixed signal change surrounded by an outer hemosiderin ring. Hematoma eccentric from the malformations was excluded. Radiotherapy dose plans were created with single or multiple isocenters (range 1-12), at the 50% isodose line in 62.2% of cases and a highly conformal dose distribution was achieved. The details of dose planning are summarized in Table I. After radiosurgery, all patients received 40 mg intravenous methylprednisolone and were discharged from hospital within a few hours.
5
Distinguishing Radiation Necrosis from Glioma
6
Single-Fraction Gamma Knife Radiosurgery
7
Radiosurgery for Refractory OCD
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Radiosurgery was indicated for five patients by psychiatrists who closely evaluated the patients for indication and during follow-up. All procedures were approved by the state of Sao Paulo Regional Medical Board. All patients had Yale–Brown Obsessive Compulsive Scale (Y-BOCS) score >26. They were treated in the gamma unit of the HCor Neuroscience, a Gamma Knife Perfexion (Elekta AB) equipment, between 2014 and 2016. Targets were located at the most ventral borders of the ALIC, touching the shell of the nucleus accumbens. A maximum dose point of 150 Gy and 4 mm collimators was used. The most ventral isocenter was planned 8–10 mm anterior to the posterior border of the anterior commissure. Radiation sensitive structures were protected; mostly, the dose to the optic structures was checked to be lower than 8 Gy. Two OCD patients were reoperated >18 months after the initial bilateral single-shot radiosurgeries and received one additional dorsal shot in each hemisphere. The other three patients were treated with only one ventral shot.
8
Gamma Knife Stereotactic Radiosurgery for Brain Metastases
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SRS was performed using the Gamma Knife Perfexion (Elekta AB). After conscious sedation and local anesthesia, a stereotactic head frame (Leksell Model G) was attached. The stereotactic gadolinium‐enhanced T1‐weighted axial magnetic resonance (MR) images with a slice thickness of 2 mm were obtained for target coordinate determination and dose planning. SRS treatment was planned with GammaPlan software 10.1.1 (Elekta AB). All BMs were treated at a margin dose of 12–24 Gy with an isodose line of 40%–80%. Dose selection depended on tumor volume and proximity to critical structures such as the brainstem and optic nerve. In general, smaller tumors distant from critical structures were treated with higher margin doses (20–24 Gy); larger tumors close to vital structures received lower margin doses (12–18 Gy).
9
Gamma Knife Radiosurgery Protocol
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GKS was performed using a Leksell Gamma Knife Perfexion (Elekta Instrument AB, Stockholm, Sweden) and multisession GKS was performed with the Gamma Knife Extend System.[22 (link)] The Leksell GammaPlan TM System planning system was used, based on 1.0-mm-thick magnetic resonance imaging (MRI) slices and computed tomography. In cases of single-fraction GKS, a prescription dose of 12–15 Gy (median 13) was applied at the 50% isodose line; in cases of multisession GKS, a prescription dose of 6.5 Gy of three fractions was applied at the 50% isodose line for 3 consecutive days.
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