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Updated: Mar 11, 2026
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after
Robert M Starke1, Dale Ding2, Hideyuki Kano3
1University of Miami, Department of Neurological Surgery, Miami, Florida.
Insights
Stereotactic radiosurgery offers a reasonable treatment for pediatric brain arteriovenous malformations (AVMs), achieving obliteration in most cases. Higher radiation doses and no prior embolization improve outcomes, but hemorrhage risk persists until obliteration.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Pediatric Neurology
Background:
- Pediatric brain arteriovenous malformations (AVMs) carry a higher hemorrhage risk than adult AVMs.
- The pediatric population was excluded from key studies comparing intervention vs. conservative management for unruptured AVMs.
Purpose of the Study:
- To analyze outcomes of stereotactic radiosurgery for pediatric AVMs (unruptured and ruptured).
- To identify predictive factors for favorable outcomes after radiosurgery in pediatric AVM patients.
Main Methods:
- A multicenter, retrospective cohort study pooling data from 7 International Gamma Knife Research Foundation centers.
- Included patients <18 years with ≥12 months follow-up.
- Defined favorable outcome as AVM obliteration, no post-radiosurgery hemorrhage, and no permanent radiation-induced changes.
Main Results:
- Overall cohort: 357 patients; mean age 12.6 years. Mean follow-up: 92 months.
- 63% AVM obliteration; 1.4% annual hemorrhage rate. Favorable outcome in 59%.
- Absence of prior embolization and higher margin dose (≥22 Gy) independently predicted favorable outcomes. Ruptured AVMs had higher obliteration and favorable outcome rates.
Conclusions:
- Stereotactic radiosurgery is a viable treatment for pediatric AVMs, with a majority achieving obliteration and favorable outcomes.
- Higher radiation doses (≥22 Gy) and lack of prior embolization are key predictors of success.
- A significant risk of hemorrhage persists during the latency period after radiosurgery until AVM obliteration.
Abstract:
OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8-17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5-35 Gy), and the mean follow-up was 92 months (range 12-266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.
