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Radiosurgery for childhood intracranial arteriovenous malformations
E I Levy1, A Niranjan, T P Thompson
1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania, USA.
Insights
Stereotactic radiosurgery is a safe and effective treatment for pediatric arteriovenous malformations (AVMs). This study shows radiosurgery achieves high obliteration rates with low morbidity in children with AVMs.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Pediatric Neurology
Background:
- Intracranial arteriovenous malformations (AVMs) in children pose management challenges due to lifelong hemorrhage risks.
- Conservative treatment carries significant risks, necessitating effective therapeutic options.
Purpose of the Study:
- To evaluate the long-term outcomes of radiosurgery for pediatric intracranial AVMs.
- To assess the safety and efficacy of radiosurgery in achieving AVM obliteration and preserving neurological function.
Main Methods:
- Retrospective review of 53 children with intracranial AVMs treated with radiosurgery, with at least 36 months of imaging follow-up.
- Analysis of patient demographics, AVM characteristics (volume, Spetzler-Martin grade), treatment parameters (marginal dose), and outcomes.
- Stratification of results based on AVM volume to determine factors influencing obliteration rates.
Main Results:
- Complete AVM obliteration was achieved in 80% of patients with AVM volumes ≤3 ml and 64.7% with volumes >3 ml to ≤10 ml.
- AVM volume was the only significant factor correlated with obliteration rates (P = 0.0109).
- Complications were rare, including one case each of brainstem and transient pulmonary edema; four patients experienced late hemorrhages.
Conclusions:
- Stereotactic radiosurgery is a safe and efficacious treatment option for selected pediatric intracranial AVMs.
- High obliteration rates and low morbidity support a primary role for radiosurgery in managing pediatric AVMs.
- AVM volume is a critical predictor of successful obliteration following radiosurgery.
Objective:
The optimal management of intracranial arteriovenous malformations (AVMs) in children remains controversial. Children with intracranial AVMs present a special challenge in therapeutic decision-making because of the early recognition of their future life-long risks of hemorrhage if they are treated conservatively. The goals of radiosurgery are to achieve complete AVM obliteration and to preserve neurological function. We present long-term outcomes for a series of children treated using radiosurgery.
Methods:
The findings for 53 consecutive children who underwent at least 36 months of imaging follow-up monitoring after radiosurgery were reviewed. The median age at the time of treatment was 12 years (range, 2-17 yr). Thirty-one children (58%) presented after their first intracranial hemorrhaging episodes, two (4%) after their second hemorrhaging episodes, and one (2%) after five hemorrhaging episodes. Nineteen children (36%) presented with unruptured AVMs, and a total of 25 children (47%) exhibited neurological deficits. AVMs were graded as Spetzler-Martin Grade I (2%), Grade II (23%), Grade III (36%), Grade IV (9%), or Grade VI (30%). The median AVM volume was 1.7 ml (range, 0.11-10.2 ml). The median marginal dose was 20 Gy (range, 15-25 Gy).
Results:
Results were stratified according to AVM volumes (Group 1, < or =3 ml; Group 2, >3 ml to < or =10 ml; Group 3, >10 ml). Twenty-eight patients (80%) in Group 1 and 11 (64.7%) in Group 2 achieved complete obliteration. The only patient in Group 3 did not achieve obliteration. Complications included brainstem edema (n = 1) and transient pulmonary edema (n = 1). Four patients experienced hemorrhaging episodes, 30, 40, 84, and 96 months after radiosurgery. Multivariate logistic regression analysis demonstrated that only volume was significantly correlated with obliteration rates (P = 0.0109).
Conclusion:
Radiosurgery is safe and efficacious for selected children with AVMs. The obliteration rates and the attendant low morbidity rates suggest a primary role for stereotactic radiosurgery for pediatric AVMs.