Jennifer Costello

Radiosurgery Successfully Treats Inoperable Arteriovenous Malformation

Jennifer Costello first became aware of her arteriovenous malformation (AVM) in 1983, when she had a seizure shortly after giving birth to her second child. A CT scan revealed that she had a five-centimeter in diameter AVM deep in the left hemisphere of her brain. She was referred to a neurosurgeon, who performed an angiogram and determined that her AVM was inoperable. Her only option was to try an embolization to decrease blood flow and prevent the development of an aneurysm, which would increase the likelihood of a catastrophic intracranial bleeding.

At the time, embolization techniques were relatively new with substantial risks of a complication such as stroke, so Jennifer decided to take her chances without undergoing the procedure. For the next 20 years, she saw her doctor for regular MRIs and managed to live a normal life without worrying too much about her AVM. During this time, she was diligent about taking her medication to prevent seizures.

Then in November 2004 while she was at work, Jennifer felt such an awful headache that she called an ambulance. At the hospital, the doctors immediately performed a CT and the doctor confirmed she had an intracranial bleed and an AVM-related aneurysm. The neuro-emergency doctor put in a shunt to lessen the pressure in her head and drain the blood from the bleed. The next day, an embolization specialist coiled the aneurysm and glued the artery that was bleeding.

It was recommended that Jennifer come back in February of 2005 for further embolization and radiation to obliterate the AVM and prevent another bleed. These procedures and recovery required that she stay in the hospital for one week. The radiosurgery treatment she underwent required that the doctors secured her head with a "halo" attached to her skull using four small screws. This procedure of securing and removing a halo can take up to four hours on the day of the treatment and at the time required a hospital stay. Jennifer was given local anesthesia and pain medication for the application and removal of the halo. After she recovered from the combined embolization and radiation treatment, she was asked to come back in six months for another MRI.

By February of the next year, Jennifer's AVM had shrunk. At that time, she was experiencing only mild side effects, which were numbness in her right foot, and a mild speech impediment. After three years, she came in for a cerebral angiogram, which revealed that the AVM was nearly closed off. Her radiation oncologist recommended that she have a second round of radiation, but she decided to wait and see if the AVM continued to shrink.

But then in March 2009, just shy of her annual appointment with her doctor, she had another intracranial bleed. So the following May, she came in for a more advanced radiosurgery treatment. Now, radiosurgery technology has evolved into a non-invasive, outpatient procedure. So, there are no screws used or incisions made, and she was in and out of the hospital in the same day. Rather than receiving an application and removal of the "halo", Jennifer received a simple head ring that was placed over her head without screws for immobilization during the treatment. In today's modern day advanced radiosurgery, neurological treatments can be administered with precision using a frame (head ring) or frameless (no head ring) based treatment. The treatment itself is shorter than her previous treatment because today's radiosurgery allows clinicians to use higher doses of radiation to treat more quickly.

After each of her radiation treatments in 2005 and 2009, Jennifer experienced a side effect called edema, a swelling in the brain. Her doctors were not surprised when it happened the second time since it had happened before, and were able to bring down the swelling with a short course of steroids.

Over the next three years, Jennifer came back for annual MRIs, had no more edema, no bleeds, and stayed on her anti-convulsant medication. When she went in for her June 2012 check up, the doctors could see from her MRI that the AVM was almost completely gone.

Now, Jennifer will follow-up with her doctors every three years for an MRI. "I don't want people to be afraid of getting radiosurgery for their treatment -- I want them to know that radiosurgery for an AVM can work. It's a positive situation."

Varian would like to thank the UCLA Medical Center and Dr. Antonio DeSalles for their invaluable assistance in the preparation of this story.