Gamma Knife® Not Just for Adults

By Rashel Stephenson

Sofia’s Scooter Crash

After 20 years at Piedmont Hospital, non-invasive Gamma Knife® stereotactic radiosurgey specialists have treated nearly 2,300 patients, including children. The following stories profile two children who benefitted from the Gamma Knife after experiencing arteriovenous malformations, or AVMs.

Doctoring a pair of skinned knees is usually as easy as wiping the tears away – and so it was with sevenyear- old Sofia Mancuso. With helmet still safely fastened, Sofia jumped back on her scooter and quickly got back to Saturday fun.

A few hours later, however, Sofia was throwing up, incoherent, and the right side of her body wasn’t moving properly. “Her breathing became shallow, her heart was racing, and I had to prop her up,” says her father, David Mancuso. “She was crashing right in front of me.”

While he was on the phone with 911, Sofia became unconscious. Paramedics raced her to Egleston Hospital, Children’s Healthcare of Atlanta, and told the Mancusos to meet them at the hospital. Later, they would find out why they weren’t invited to ride with their young daughter – the EMTs thought Sofia would not make it.

Met by the hospital chaplain, the Mancusos were updated: Sofia was having a CT scan, and she had been hooked up to IVs for hydration and a respirator to help her breathe. The Mancusos were asked to sign a consent form for surgeons to perform brain surgery.

Andrew Reisner, M.D., pediatric neurosurgeon, was first concerned with relieving the pressure in Sofia’s brain by draining the built-up blood and fluid. Later, a full catheter angiogram would reveal the cause of Sofia’s brain bleed – an arteriovenous malformation, or AVM.

“An AVM is a bird’s nest of tangled blood vessels,” explains Reisner. “They are congenital, like a birth mark, and can occur anywhere in the body. But brain AVMs are of special concern because of the damage they cause when they bleed – and they often bleed abruptly.”

Most people, including adults and children, never experience significant symptoms of an AVM. On occasion, AVMs are diagnosed incidentally – like when a head CT or MRI is obtained following a head injury. But in Sofia’s case, Dr. Reisner says she likely fell off her scooter as a result of the sudden hemorrhage in her brain.

After 12 days in the pediatric intensive care unit, Sofia’s brain pressure had finally stabilized. She was transferred to Scottish Rite, Children’s Healthcare of Atlanta, for inpatient rehabilitation to recover the use of her right hand and foot. A few days later, her parents drove her to Piedmont Hospital to have Gamma Knife® radiosurgery to treat the source of the problem – the AVM.

For more than 10 years, Dr. Reisner has worked closely with colleagues at Piedmont Hospital and has treated more than 150 pediatric patients with the Gamma Knife. The partnership – between neurosurgery at Children’s Healthcare of Atlanta, and radiation oncology and anesthesia at Piedmont Hospital – has evolved into one of the largest Gamma Knife pediatric services in the world.

“Gamma Knife surgery is a very attractive option in children with AVMs,” Dr. Reisner says. “Radiation causes the AVM to undergo a slow obliteration over approximately one to three years after treatment. Eventually, the blood vessel narrows so much that there is no blood flow through the AVM, and it is considered cured.”

Ninety percent of the time, pediatric AVMs are cured with a single Gamma Knife treatment. It’s too soon to tell with Sofia – she just had her procedure in December 2009. Her parents know the risk of re-bleeding is 2 to 3 percent per year.

“We’re taking it easy until we know the AVM is completely gone,” says Mancuso. “We’re taking a temporary break from the scooter; now she’s busy with a new hobby – art.” One of Sofia’s few memories of her experience is being wheeled around the hospital halls by her father during rehab, talking about the art created by other pediatric patients.

It might take Sofia two years to fully recover, but in the meantime, she has routine occupational therapy and regular check-ups to monitor the deterioration of the AVM. And at home, she continues to tune her fine motor skills by creating precious pieces of art for her family.