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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Radiosurgery of brain arteriovenous malformations in children
D R Buis1, C M F Dirven, F J Lagerwaard
1Dept. of Neurosurgery, Neurosurgical Center Amsterdam, VU University Medical Center, 2F-005, PO Box 7057, 1007 MB Amsterdam, The Netherlands. dr.buis@vumc.nl
Insights
Stereotactic radiosurgery offers effective treatment for pediatric brain arteriovenous malformations (bAVMs), achieving a 68% obliteration rate. However, microsurgery is preferred for immediate risk reduction in suitable cases.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Pediatric Neurology
Background:
- Brain arteriovenous malformations (bAVMs) are complex vascular lesions.
- Pediatric bAVMs present unique treatment challenges.
- Stereotactic radiosurgery (SRS) is an option for select pediatric bAVMs.
Purpose of the Study:
- To evaluate the efficacy and safety of LINAC-based SRS for pediatric single bAVMs.
- To assess obliteration rates and clinical outcomes in children treated with SRS.
- To compare SRS outcomes with existing pediatric neurosurgical data.
Main Methods:
- Retrospective review of 22 pediatric patients (<18 years) with single bAVMs treated with SRS.
- Minimum 24-month follow-up or earlier obliteration.
- Analysis of patient age, bAVM volume, prescribed radiation dose, and AVM score.
Main Results:
- Crude obliteration rate of 68% at median 24-month follow-up.
- Actuarial obliteration rates of 45% (2 years) and 64% (3 years).
- Lower AVM scores correlated with better outcomes (71% vs. 20%) and higher obliteration rates (P=0.03).
- Post-SRS hemorrhage rate of 1.3%/year; one fatal hemorrhage occurred.
- Radiation-induced changes observed in 36% of patients.
Conclusions:
- SRS is a relatively effective, minimally invasive treatment for small pediatric bAVMs.
- Low rebleeding rates are achievable with prior endovascular elimination of high-risk sites.
- Microsurgery may be preferred over SRS due to immediate risk reduction, despite SRS effectiveness.
Objective:
The authors describe their experience in treating 22 children with a single brain arteriovenous malformation (bAVM) using a dedicated LINAC stereotactic radiosurgery unit.
Methods:
The findings of 22 consecutive patients < or = 18 years of age who underwent radiosurgery for a single bAVM and with at least 24 months of follow-up, or earlier proven obliteration,were reviewed. The median age at radiosurgery was 13.8 years,with a hemorrhagic presentation in 86%. Median bAVM-volume was 1.8 ml, with a median prescribed marginal dose of 19.0 Gy.
Results:
The crude complete obliteration-rate was 68% (n = 15) after a median follow-up of 24 months. The actuarial obliteration- rate was 45 % after two years and 64 % after three years. Patients with a radiosurgery-based AVM score < or = 1 more frequently had an excellent outcome than patients with a bAVM score > 1 (71% vs. 20%, P = 0.12), as well as an increased obliteration rate (P = 0.03) One patient died from a bAVM-related hemorrhage 27 months after radiosurgery, representing a postradiosurgery hemorrhage rate of 1.3%/year for the complete followup interval. Overall outcome was good to excellent in 68% (n = 15). Radiation-induced changes on MR imaging were seen in 36% (n = 8) after a median interval of 12.5 months, resulting in deterioration of pre-existing neurological symptoms in one patient.
Conclusions:
Radiosurgery is a relatively effective, minimally invasive treatment for small bAVMs in children. The rebleeding rate is low, provided that known predilection places for bleeding had been endovascularly eliminated.Our overall results compare unfavourably to recent pediatric microsurgical series, although comparison between series remains imprecise. Nevertheless, when treatment is indicated in a child with a bAVM that is amenable to both microsurgery or radiosurgery, microsurgery should carefully be advocated over radiosurgery, because of its immediate risk reduction.
