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Essibayi MA, Tos SM, Vadset T, Behbahani M, Lasala PA, Altschul DJ, Sheehan JP. Stereotactic Radiosurgery Outcomes in Arteriovenous Malformations: A Pediatric-Adult Comparative Meta-Analysis. World Neurosurg 2024:S1878-8750(24)01405-0. [PMID: 39151696 DOI: 10.1016/j.wneu.2024.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is an established treatment for brain arteriovenous malformations (AVMs), but outcomes between pediatric and adult populations are not well compared. We conducted a systematic review and meta-analysis comparing SRS outcomes for pediatric versus adult AVMs. METHODS PubMed was searched for studies reporting SRS outcomes for pediatric or adult AVMs up to January 2024. Primary outcome was obliteration rate, with secondary outcomes including post-SRS hemorrhage, symptomatic radiation-induced changes (RICs), and permanent RICs. Pooled estimates were calculated using random effects models. RESULTS Analysis included 22 studies with 3469 patients (1316 pediatric, 2153 adult). Pooled obliteration rate was 63% (95% confidence interval: 56%-70%) overall, with no significant difference between pediatric (61%) and adult (67%) cohorts (P = 0.38). Post-SRS hemorrhage rates were similar (5% pediatric, 6% adult, P = 0.60). Symptomatic RICs occurred in 9% (95% confidence interval: 6%-13%) overall, with 10% in both cohorts (P = 0.91). Permanent RIC rates were 4% in pediatric and 3% in adult cohorts (P = 0.43). Cyst formation (0.6%) and radiation-induced tumors (0.2%) were rare. All-cause mortality was significantly lower in the pediatric cohort (2.6% vs. 9.8%, P = 0.003). Hemorrhagic AVM presentation was inversely correlated with symptomatic RICs across both groups. CONCLUSIONS SRS is a reasonable treatment option for appropriately selected AVM patients in both pediatric and adult populations, offering comparable obliteration rates and adverse event profiles. The lower mortality in pediatric patients underscores the importance of early intervention in this population given their high cumulative lifetime rupture risks.
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Affiliation(s)
- Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Taylor Vadset
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mandana Behbahani
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patrick A Lasala
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David J Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Ashir Shafique M, Saqlain Mustafa M, Haseeb A, Mussarat A, Arham Siddiq M, Faheem Iqbal M, Iqbal J, Kuruba V, Patel T. Trapped temporal horn: From theory to practice, a systematic review of current understanding and future perspectives. World Neurosurg X 2024; 23:100345. [PMID: 38511157 PMCID: PMC10950730 DOI: 10.1016/j.wnsx.2024.100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/05/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Background The Entrapped Temporal Horn (ETH) is characterized by localized enlargement of the temporal horn of the lateral ventricle of the brain. This study aimed to investigate the factors, development, prognosis, and effective treatment. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in major research databases. The inclusion criteria included patients of all ages with TTH diagnosis in cohort studies, case series, and case reports. Results Our study included 160 patients and 49 studies. The major causes of TTH were neoplastic lesions (42.3%), infections (22.3%), and cystic disease (13.08%). Of these cases, 71 were unrelated to cranial surgery, while 89 were unrelated to prior surgeries. Headache was the most common symptom (41.91%), followed by seizures (13.20%), drowsiness (12.50%) and memory loss (11.00%). Surgery was not required in 17 patients. Fenestration of the trapped temporal horn was performed in 24 patients, while VP/VA shunt surgeries were performed in the majority (57 patients) owing to favorable outcomes, lower revision rates, and extensive experience. However, TTH recurred in six of the 21 patients who underwent endoscopic ventriculocisternostomy. Tumors were the main cause, and isolated headache was the most frequent symptom. Ventriculoperitoneal shunts (VPS) are preferred because of their positive outcomes, lower revision rates, and wider expertise. Tumors near the trigonal area pose a higher risk. Conclusion Although TTH remains a rare condition, VPS continues to be the most widely preferred procedure among surgeons.
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Affiliation(s)
| | | | - Abdul Haseeb
- Department of Neurosurgery, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Abdullah Mussarat
- Department of Neurosurgery, Jinnah Sindh Medical University, Karachi, Pakistan
| | | | | | - Javed Iqbal
- King Edward Medical University, Lahore, Pakistan
| | | | - Tirath Patel
- American University of Antigua College of Medicine, Antigua and Barbuda
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Pettersson SD, Elrafie MK, Makarewicz J, Klepinowski T, Skrzypkowska P, Filo J, Ramirez-Velandia F, Fodor T, Lau T, Szmuda T, Young M, Ogilvy CS. Long-Term Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: A Systematic Review. World Neurosurg 2024; 186:197-203.e1. [PMID: 38537789 DOI: 10.1016/j.wneu.2024.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND The long-term outcomes after stereotactic radiosurgery (SRS) for pediatric brain arteriovenous malformations (AVMs) remain poorly understood given the paucity of longitudinal studies. A systematic review was conducted to pool cumulative incidences for all outcomes. METHODS PubMed, Embase, and Web of Science were queried to systematically extract potential references. The articles relating to AVMs treated via SRS were required to be written in English, involve pediatric patients (<18 years of age), and include a mean follow-up period of >5 years. Individual patient data were obtained to construct a pooled Kaplan-Meier plot on obliteration rates over time. RESULTS Among the 6 studies involving 1315 pediatric patients averaging a follow-up period of 86.6 months (range, 6-276), AVM obliteration was observed in 66.1% with cumulative probabilities of 48.28% (95% confidence interval [CI], 41.89-54.68), 76.11% (95% CI, 67.50-84.72), 77.48% (95% CI, 66.37-88.59) over 3, 5, and 10 years, respectively. The cumulative incidence of post-SRS hemorrhage, tumors, cysts, and de novo seizures was 7.2%, 0.3%, 1.6%, and 1.5%, respectively. The cumulative incidence of radiation-induced necrosis, edema, radiologic radiation-induced changes (RICs), symptomatic RICs, and permanent RICs were 8.0%, 1.4%, 28.0%, 8.7%, and 4.9%, respectively. CONCLUSIONS Studies assessing long-term outcomes after SRS are moderate in quality and retrospective. Thus, interpretation with caution is advised given the variable degree of loss to follow-up, which suggests that complication rates may be higher than the values stated in the literature. Future prospective studies are needed to validate these findings.
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Affiliation(s)
- Samuel D Pettersson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Mohamed K Elrafie
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Jakub Makarewicz
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | | | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tzak Lau
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomasz Szmuda
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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4
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Gao D, Meng X, Jin H, Liu A, Sun S. Assessment of gamma knife radiosurgery for unruptured cerebral arterioveneus malformations based on multi-parameter radiomics of MRI. Magn Reson Imaging 2022; 92:251-259. [PMID: 35870722 DOI: 10.1016/j.mri.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/13/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The treatment of Gamma knife radiosurgery (GKS) for unruptured Arteriovenous Malformations (AVM) remains controversial. A safe, effective and non-invasive method to predict outcome seems attractive for GKS. The purpose of this study was to develop and validate a MRI based multi-parameter radiomics model predicting the outcome of GKS for unruptured AVM. METHODS Eighty-eight unruptured AVM patients who initial underwent GKS between January 2011 and December 2016 in our hospital were included in this retrospective study. Patients were divided into two groups named as favourable and unfavourable outcome, according to the clinical outcome. Favourable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). Multivariate logistic regression analysis was used to select appropriate clinical features and construct a clinical predicting model. In terms of radiomic model, manually segmentation and radiomics extracted were performed on each AVM lesions. Finally, 1684 radiomics features were extracted and Recursive Feature Elimination (RFE) method combined with Random forest classifier were used for feature selection and model construction. The performance of the radiomics model was evaluated by the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In addition, the favourable group was further divided into early and late respond subgroup according to the time of obliteration evaluated by 2 years. The selected features were further compared according the respond time. RESULTS The median duration of neuroimaging follow-up was 65 months, 56 patients showed favourable outcome and 17 patients were observed obliteration within 2 years. The radiomics model constructed by 12 selected features achieved significant higher AUC of 0.88 (95% confidence interval 0.87-0.90) than traditional scoring system for predicting AVM outcome. Two selected radiomics features named "Dependence Variance" and "firstorder-Skewness" were found significant difference between the patients with early or late-respond. CONCLUSIONS The results suggest that the radiomics features could be successfully used for the pretreatment prediction of outcome for GKS in unruptured AVMs, which is helpful for decision-making process on unruptured AVM patients.
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Affiliation(s)
- Dezhi Gao
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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5
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Clinical Characteristics and Multimodality Therapy Outcomes in 304 Pediatric Patients with Cerebral Arteriovenous Malformations. World Neurosurg 2022; 168:e150-e161. [DOI: 10.1016/j.wneu.2022.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022]
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Zhu S, Brodin NP, Garg MK, LaSala PA, Tomé WA. Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Giugliano M, Scafa AK, Chiarella V, Di Bartolomeo A, Bruzzaniti P, D'Andrea G, Salvati M, Santoro A. Entrapment of the temporal horn: case series and systematic review of literature. J Neurosurg Sci 2020; 65:532-540. [PMID: 33297607 DOI: 10.23736/s0390-5616.20.05111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Entrapment of the temporal horn (ETH) is a form of focal, obstructive hydrocephalus. Etiology and clinical presentation are diversified. Though known since 1947, standard treatment has not yet been defined. The objective of our study was to perform a systematic review on ETH. Data from patients treated at our Institution from 2008 to 2019 were retrospectively collected and analyzed. A systematic PRISMA review of literature was also performed using PubMed and Google Scholar. 121 cases (mean age 41 years; M/F ratio 1/1) were analyzed. In 65 (vs 56) cases (53.7% vs 46.3%) ETH was not surgery related. Headache was the most common symptom (42%). "Major" treatments were (1) ventriculoperitoneal/ventriculoatrial shunt (42 cases, 34.7%), and (2) endoscopic ventriculocisternostomy (12 cases, 9.9%). In the first group, no perioperative complications were found, 39 patients (92.9%) had a favorable outcome, 3 patients (7.1%) died for the underlying disease, 4 cases (9.5%) went through revision; also considering the cases in which another procedure was performed as definitive treatment, shunt failures were 6 (13.6%). In the second group, 1 case (8.3%) developed a deep intracerebral hemorrhage, 11 cases (91.6%) had a favorable long-term outcome, 1 case (8.3%) had a favorable short-term outcome; also considering the cases in which another procedure was performed as definitive treatment, endoscopic ventriculocisternostomy failures were 6 (37.5%). Described as uncommon, ETH is probably underestimated. Early diagnosis and appropriate treatment are critical. VP shunt is still the most commonly performed treatment. Further randomized clinical trials are, however, needed to establish the gold standard.
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Affiliation(s)
- Marco Giugliano
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy
| | - Anthony K Scafa
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy -
| | - Vito Chiarella
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy
| | | | - Placido Bruzzaniti
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy
| | - Giancarlo D'Andrea
- Department of Neurosurgery, Fabrizio Spaziani Hospital, Frosinone, Italy
| | - Maurizio Salvati
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy
| | - Antonio Santoro
- Department of Neurological Sciences, Neurosurgery, La Sapienza University of Rome, Rome, Italy
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8
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Börcek AÖ, Çeltikçi E, Aksoğan Y, Rousseau MJ. Clinical Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations in Pediatric Patients: Systematic Review and Meta-Analysis. Neurosurgery 2020; 85:E629-E640. [PMID: 31131849 DOI: 10.1093/neuros/nyz146] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) in pediatric patients exhibit remarkable differences in terms of management and outcomes. Owing to a paucity of relevant data pertaining to AVMs in pediatric patients, special interest and investigation are required for an improved understanding of the available evidence by clinicians. OBJECTIVE To determine the clinical outcomes of single-session stereotactic radiosurgery (SRS) for AVMs in pediatric patients. METHODS A systematic literature review was performed to identify studies that reported the outcomes of SRS for AVMs in pediatric patients. Data pertaining to variables such as obliteration rate, post-SRS new hemorrhage rate, post-SRS new neurological deficit rate, and mortality rate were extracted and analyzed using meta-analysis techniques. RESULTS Based on pooled data from 20 studies with 1212 patients, single-session SRS resulted in complete obliteration in 65.9% (95% confidence interval [CI], 60.5%-71.1%; I2 = 66.5%) patients. Overall complication rate (including new hemorrhage, new neurodeficit, and mortality) was 8.0% (95% CI, 5.1%-11.5%; I2 = 66.4%). Post-SRS new neurological deficit rate was 3.1% (95% CI, 1.3%-5.4%; I2 = 59.7%), and post-SRS hemorrhage rate was 4.2% (95% CI, 2.5%-6.3%; I2 = 42.7%). There was no significant difference between studies disaggregated by treatment method (Gamma Knife [Elekta AB] vs other), treatment year (before year 2000 vs after year 2000), median AVM volume reported (≥3 vs <3 cm3), median dose reported (≥20 vs <20 Gy), or follow-up period (≥36 vs <36 mo). CONCLUSION Single-SRS is a safe treatment alternative that achieves high obliteration rates and acceptable complication rates for AVMs in pediatric patients.
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Affiliation(s)
- Alp Özgün Börcek
- Division of Pediatric Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Emrah Çeltikçi
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Yiğit Aksoğan
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
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Liu J, Long SR, Li GY. Entrapment of the temporal horn secondary to postoperative gamma-knife radiosurgery in intraventricular meningioma: A case report. World J Clin Cases 2019; 7:2894-2898. [PMID: 31616708 PMCID: PMC6789398 DOI: 10.12998/wjcc.v7.i18.2894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/23/2019] [Accepted: 07/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Entrapment of the temporal horn (ETH) is a rare pathologic condition. It is a kind of focal hydrocephalus caused by obstruction of flow pathway of cerebrospinal fluid. It is caused by various conditions, but ETH secondary to postoperative gamma-knife radiosurgery (GKS) is extremely rare.
CASE SUMMARY A 52-year old previously healthy woman underwent resection of a large intraventricular meningioma. A small fragment of residual tumor with no obvious enlargement of the temporal horn was observed 3 mo after surgery, and she was referred for GKS. Two months after GKS, she complained of headache and progressive paralysis of the left limb. Magnetic resonance imaging revealed enlargement of the temporal horn. There was a second procedure to resect the residual tumor 8 mo after GKS. After the second procedure, she recovered smoothly. As of the date of this writing, she has remained in good condition.
CONCLUSION This case reminds us that ETH should be considered in the treatment of intraventricular meningiomas, especially before GKS.
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Affiliation(s)
- Jia Liu
- Department of Neurosurgery, the First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Sheng-Rong Long
- Department of Neurosurgery, the First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Guang-Yu Li
- Department of Neurosurgery, the First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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10
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Hasegawa T, Kato T, Naito T, Tanei T, Torii J, Ishii K, Tsukamoto E. Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 1: Analysis of Nidus Obliteration Rates and Related Factors. World Neurosurg 2019; 126:e1518-e1525. [PMID: 30922904 DOI: 10.1016/j.wneu.2019.03.176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Little is known about long-term outcomes for pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS). This study investigated annual hemorrhage rates and nidus obliteration rates, and the factors affecting them, in pediatric AVMs treated with GKRS. METHODS We examined 189 pediatric AVM patients (age ≤15 years) who underwent GKRS and had at least 12 months of follow-up. The Spetzler-Martin (S-M) grade was I in 29 patients (15%), II in 57 (30%), III in 82 (43%), IV in 16 (9%), and V in 5 (3%). The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS The mean follow-up period was 136 months. During a cumulative latency period to nidus obliteration of 813 years, 23 hemorrhages occurred, resulting in an annual post-GKRS hemorrhage rate of 2.8%. The cumulative hemorrhage rates after GKRS were 3.3%, 8.5%, and 11.9% at 3, 5, and 10 years, respectively. Higher S-M grade was significantly associated with intracranial hemorrhages during the latency period (P < 0.001). The actuarial nidus obliteration rates with repeated GKRS were 64% and 81% at 5 and 10 years, respectively. Absence of pre-GKRS embolization (P = 0.023) and higher marginal dose (P = 0.029) were significant factors predicting nidus obliteration. CONCLUSIONS GKRS is a reasonable treatment option in pediatric AVMs to prevent future hemorrhages. Because higher S-M grade AVMs are more likely to hemorrhage during the latency period, a combined therapy with endovascular embolization should be considered to prevent AVM rupture.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan.
| | - Takenori Kato
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takehiro Naito
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Jun Torii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Eisuke Tsukamoto
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
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11
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Ai X, Ye Z, Xu J, You C, Jiang Y. The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis. J Neurosurg Pediatr 2019; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/06/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs. METHODS The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients. CONCLUSIONS Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation. ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; NOS = Newcastle-Ottawa Scale; OR = odds ratio; SM = Spetzler-Martin.
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Affiliation(s)
| | | | | | | | - Yan Jiang
- 2Nursing Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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12
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Capitanio JF, Panni P, Gallotti AL, Gigliotti CR, Scomazzoni F, Acerno S, Del Vecchio A, Mortini P. Radiosurgical treatment of arteriovenous malformations in a retrospective study group of 33 children: the importance of radiobiological scores. Childs Nerv Syst 2019; 35:301-308. [PMID: 30474715 DOI: 10.1007/s00381-018-4008-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Arteriovenous malformations' (AVMs) obliteration depends on several factors; among the many factors that must be considered to obtain a high rate of obliteration and a low rate of complications, Flickinger-Pollock Score (FPS) seems to have an important role but still have to be validated in the pediatric population while Paddick-Conformity Index (PCI) still has no demonstration of its utility on the outcome and is considered only as a treatment quality marker. METHODS We retrospectively analyzed 33 consecutive children (2-18 years) with an AVM, treated with stereotactic radiosurgery Gamma Knife (SRS-GK) from 2001 to 2014 in our institution. We assess angiographic (DSA) Obliteration Rate (OR) as well FPS and PCI to draw conclusions. RESULTS DSA-OR was 60.6% with a rate of hemorrhage of 0%. median target volume (TV) was 3.60 cc (mean 4.32 ± 3.63; range 0.15-14.2), median PD was 22 Gy (mean 21.4 ± 2.6; range 16.5-25). Median percentage of coverage was 98% (mean 97 ± 3; range 84-100). The median modified FPS was 0.78 (mean 0.89 ± 0.52; range 0.21-2.1) and highly correlate with OR (p = 0.01). The median PCI was 0.65 (mean 0.65 ± 0.14; range 0.34-0.95) A PCI lower than 0.57 highly correlates with final OR (p = 0.02). CONCLUSION SRS-GK was safe and gradually effective in children. A prescription dose-like that used in adult population (i.e. > 18 and between 20 and 25 Gy) is essential to achieve obliteration. A PD of 23 Gy and 22 Gy did impact OR, respectively (p = 0.02) and (p = 0.05). FPS and PCI are valuable scores that seem to correlate with the OR also in the pediatric population although further prospective studies are needed to confirm these observations.
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Affiliation(s)
- Jody Filippo Capitanio
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | - Pietro Panni
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Luigi Gallotti
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Carmen Rosaria Gigliotti
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesco Scomazzoni
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefania Acerno
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
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Park CK, Choi SK, Lee SH, Choi MK, Lim YJ. Clinical outcomes and radiosurgical considerations for pediatric arteriovenous malformation: influence of clinical features on obliteration rate. Childs Nerv Syst 2017; 33:2137-2145. [PMID: 28871374 DOI: 10.1007/s00381-017-3579-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Gamma knife radiosurgery (GKRS) is an established treatment modality for brain arteriovenous malformation (AVM), but there have been few published studies examining the relationship between clinical features of AVM and successful obliteration with GKRS in pediatric patients. In the current study, we investigate the outcomes of GKRS for pediatric patients with brain AVM and analyze the variables that influence obliteration. METHODS We analyzed 68 pediatric patients (≤ 18 years) with a mean follow-up period of 61.9 months (range 6-215 months). The following parameters were analyzed to determine their influence on obliteration of AVM treated by GKRS: age, sex, target volume, irradiation dose, prior treatment, location of AVM, nidus structure, velocity of AVM, location of venous drainage, number of feeding arteries, and initial presenting symptoms. Also, we estimated clinical factors which should be considered during the follow-up period. RESULTS Of the 68 patients, complete obliteration was confirmed in 26 (38.2%) by cerebral angiography. The response rate of AVM for GKRS was 92.6%. No significant association was observed between any of the parameters investigated and the obliteration of AVM, with the exception of number of feeding arteries, which exhibited a statistically significant difference by univariate analysis (p = 0.003). However, on multivariate analysis, nidus structure (p = 0.007), velocity of the main arterial phase (p = 0.013), velocity of the feeding artery phase (p = 0.004), and the number of feeding arteries (p = 0.018) showed statistical significance. CONCLUSION GKRS yielded good long-term clinical outcomes in most pediatric patients. Multiple arterial feeding vessels, diffuse nidus structure, and fast flow of AVM were specific factors associated with a low rate of obliteration in pediatric AVMs.
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Affiliation(s)
- Chang Kyu Park
- Department of Neurosurgery, Department of Medicine, Graduate School, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, South Korea
| | - Seok Keun Choi
- Department of Neurosurgery, Department of Medicine, Graduate School, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, South Korea.
| | - Sung Ho Lee
- Department of Neurosurgery, Department of Medicine, Graduate School, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, South Korea
| | - Man Kyu Choi
- Department of Neurosurgery, Department of Medicine, Graduate School, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, South Korea
| | - Young Jin Lim
- Department of Neurosurgery, Department of Medicine, Graduate School, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, South Korea
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Ilyas A, Chen CJ, Ding D, Buell TJ, Raper DMS, Lee CC, Xu Z, Sheehan JP. Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2017; 83:365-376. [DOI: 10.1093/neuros/nyx502] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/11/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Neurosurgery, Barrow Neurologic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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15
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Patibandla MR, Ding D, Xu Z, Sheehan JP. Stereotactic Radiosurgery for Pediatric High-Grade Brain Arteriovenous Malformations: Our Experience and Review of Literature. World Neurosurg 2017; 102:613-622. [DOI: 10.1016/j.wneu.2017.03.064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/23/2023]
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16
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Rajshekhar V, Moorthy RK, Jeyaseelan V, John S, Rangad F, Viswanathan P, Ravindran P, Singh R. Results of a Conservative Dose Plan Linear Accelerator–Based Stereotactic Radiosurgery for Pediatric Intracranial Arteriovenous Malformations. World Neurosurg 2016; 95:425-433. [DOI: 10.1016/j.wneu.2016.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 11/15/2022]
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Yang W, Anderson-Keightly H, Westbroek EM, Caplan JM, Rong X, Hung AL, Colby GP, Coon AL, Tamargo RJ, Huang J, Ahn ES. Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations. J Neurosurg Pediatr 2016; 18:329-38. [PMID: 27153378 DOI: 10.3171/2016.3.peds15715] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Compared with the general population, the specific natural history of arteriovenous malformations (AVMs) in pediatric patients is less well understood. Furthermore, few pediatric studies have compared posttreatment hemorrhagic risk and functional outcome across different treatment modalities. The objective of this study was to elucidate these points. METHODS The authors retrospectively reviewed all pediatric patients with AVMs evaluated at their institution between 1990 and 2013. The AVM natural history was represented by hemorrhagic risk during the observation period. For treated patients, the observation period was defined as the interval between diagnosis and treatment. Posttreatment hemorrhagic risk and functional outcomes were also assessed. RESULTS A total of 124 pediatric patients with AVMs were evaluated, and 90 patients (72.6%) were retained through follow-up. The average patient age was 13.3 ± 3.8 years, with a mean follow-up period of 9.95 years. The overall AVM obliteration rate was 59.7%. Radiosurgery had an obliteration rate of 49.0%. Thirteen patients were managed conservatively. Four patients under observation hemorrhaged during a total interval of 429.4 patient-years, translating to an annual risk of 0.9%. Posttreatment hemorrhagic risk by treatment modalities were categorized as follows: surgery ± embolization (0.0%), radiosurgery ± embolization (0.8%), embolization alone (2.8%), surgery + radiosurgery ± embolization (3.5%), and observation (0.8%). A significantly higher risk of posttreatment hemorrhage was observed for patients with hemorrhagic presentation (p = 0.043) in multivariate analysis. Seizure presentation, frontal lobe location, nonheadache presentation, and treatment modality were significantly associated with increased risk of poor functional outcomes. CONCLUSIONS In this study of pediatric patients with AVMs, the natural history of hemorrhage was relatively low at 0.9%. Resection remained the optimal management for hemorrhage control and functional outcome perseverance in these pediatric patients with AVMs. AVM obliteration is a valid treatment goal, especially for patients with ruptured presentation, to prevent further hemorrhages later in life.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaoming Rong
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward S Ahn
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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18
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Braileanu M, Yang W, Caplan JM, Lin LM, Radvany MG, Tamargo RJ, Huang J. Interobserver Agreement on Arteriovenous Malformation Diffuseness Using Digital Subtraction Angiography. World Neurosurg 2016; 95:535-541.e3. [PMID: 27565471 DOI: 10.1016/j.wneu.2016.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Arteriovenous malformation (AVM) diffuseness has been shown to be prognostic of treatment outcomes. We assessed interobserver agreement of AVM diffuseness among physicians of different specialty and training backgrounds using digital subtraction angiography (DSA). METHODS All research protocols were approved by the institutional review board for this retrospective chart review. In a single-blinded setting, 2 attending neurosurgeons, 1 attending interventional neuroradiologist, and 1 senior neurosurgical resident rated 80 DSA views of 36 AVMs as either compact or diffuse. Individual interobserver agreement and subgroup agreement were analyzed using κ agreement and intraclass correlation coefficient. RESULTS Disagreement regarding AVM diffuseness occurred in 43.8% of all DSA views (n = 80). Interobserver κ agreement on AVM diffuseness using DSA views among 4 physicians ranged from fair (κ = 0.40 [95% confidence interval (CI) = 0.22-0.58]) to substantial (κ = 0.65 [95% CI = 0.48-0.81]), whereas total intraclass correlation coefficient was 0.81 (95% CI = 0.73-0.87). For the 36 AVMs, κ agreement ranged from fair (κ = 0.36 [95% CI = 0.13-0.60]) to moderate (κ = 0.57 [95% CI = 0.35-0.79]), whereas intraclass correlation coefficient among all 4 physicians was 0.68 (95% CI = 0.47-0.82). Moderate agreement on AVM diffuseness (n = 80) was found between attending and resident assessments (κ = 0.57 [95% CI = 0.39-0.75]) and between neurosurgeon and interventional neuroradiologist assessments (κ = 0.55 [95% CI = 0.37-0.73]). CONCLUSIONS Agreement of individual physicians on AVM diffuseness varies from fair to substantial. Objective and three-dimensional measures of AVM diffuseness should be developed for consistent clinical application.
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Affiliation(s)
- Maria Braileanu
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, California, USA
| | - Martin G Radvany
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Radiology, WellSpan York Hospital, York, Pennsylvania, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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19
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Nicolato A, Longhi M, Tommasi N, Ricciardi GK, Spinelli R, Foroni RI, Zivelonghi E, Zironi S, Dall'Oglio S, Beltramello A, Meglio M. Leksell Gamma Knife for pediatric and adolescent cerebral arteriovenous malformations: results of 100 cases followed up for at least 36 months. J Neurosurg Pediatr 2015; 16:736-47. [PMID: 26339954 DOI: 10.3171/2015.4.peds158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECT The goal of this study was to evaluate advantages, risks, and failures of Gamma Knife radiosurgery (GKRS) in a large series of pediatric and adolescent patients with cerebral arteriovenous malformations (cAVMs) who were followed up for at least 36 months. METHODS Since February 1993, 100 pediatric and adolescent patients (≤ 18 years of age) with cAVMs have undergone GKRS at the authors' institution and were followed up for at least 36 months. Forty-six patients were boys and 54 were girls; the mean age was 12.8 years (range 3-18 years). Hemorrhage, either alone or combined with seizure, was the clinical onset in 70% of cases. The mean pre-GK cAVM volume was 2.8 ml; 92% of cAVMs were Spetzler-Martin (S-M) Grades I-III. Most lesions (94%) were in eloquent or deep-seated brain regions, according to S-M classification. The parameters for mean and range in treatment planning were prescription isodose 53.8% (40%-90%); prescription dose (PD) 20.2 Gy (9.0-26.4 Gy); maximal dose (MD) 37.8 Gy (18-50 Gy); and number of shots 4.7 (1-17). On the day of GKRS, stereotactic CT or stereotactic MRI and digital subtraction angiography were used. RESULTS Obliteration rate (OR) was angiographically documented in 75 of 84 cases (89.3%) after single-session GKRS, with actuarial ORs at 3 and 5 years of 68.0% and 88.1%, respectively. A repeat treatment was performed in 7 patients (6 with obliteration), and 16 patients with cAVMs underwent staged treatment (9 of them were angiographically cured). Thus, the overall OR was 90%, with actuarial ORs at 3, 5, and 8 years of 59.0%, 76.0%, and 85.0%, respectively. Permanent symptomatic GK-related complications were observed in 11% of cases, with surgical removal of enlarged mass seen on post-RS imaging needed in 5 cases. Hemorrhage during the latency period occurred in 9% of patients, but surgical evacuation of the hematoma was required in only 1 patient. One patient died due to rebleeding of a brainstem cAVM. Radiosurgery outcomes varied according to cAVM sizes and doses: volumes ≤ 10 ml and PDs > 16 Gy were significantly associated with higher ORs and lower rates of permanent complication and bleeding during the latency period. CONCLUSIONS The data from this study reinforce the conclusion that GKRS is a safe and effective treatment for pediatric and adolescent cAVMs, yielding a high OR with minimal permanent severe morbidity and no mortality. The very low frequency of severe hemorrhages during the latency period further encourages a widespread application of RS in such patients. Univariate analysis found that modified RS-based cAVM score, nidus volume, PD, integral dose, S-M grade, and preplanned treatment (the last 2 parameters were also confirmed on multivariate analysis) significantly influenced OR. Lower S-M grades and single-session planned treatments correlated with shorter treatment obliteration interval on univariate analysis. This statistical analysis suggests that a staged radiosurgical treatment should be planned when nidus volume > 10 ml and/or when the recommended PD is ≤ 16 Gy.
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Affiliation(s)
| | | | - Nicola Tommasi
- Centro Interdipartimentale di Documentazione Economica (C.I.D.E.), University of Verona
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20
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Gross BA, Storey A, Orbach DB, Scott RM, Smith ER. Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience. J Neurosurg Pediatr 2015; 15:71-7. [PMID: 25360855 DOI: 10.3171/2014.9.peds146] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0-2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Potts MB, Sheth SA, Louie J, Smyth MD, Sneed PK, McDermott MW, Lawton MT, Young WL, Hetts SW, Fullerton HJ, Gupta N. Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes. J Neurosurg Pediatr 2014; 14:1-11. [PMID: 24766309 DOI: 10.3171/2014.3.peds13381] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
UNLABELLED OBJECT.: Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. METHODS The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. RESULTS A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm(3) (range 0.09-62.3 cm(3)), and median prescription marginal dose used was 17.5 Gy (range 12-20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18-20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%-37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0-2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. CONCLUSIONS A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.
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Sheth SA, Potts MB, Sneed PK, Young WL, Cooke DL, Gupta N, Hetts SW. Angiographic features help predict outcome after stereotactic radiosurgery for the treatment of pediatric arteriovenous malformations. Childs Nerv Syst 2014; 30:241-7. [PMID: 23892391 DOI: 10.1007/s00381-013-2231-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Arteriovenous malformations (AVMs) are a frequent cause of hemorrhagic stroke in children. Stereotactic radiosurgery (SRS) is an established treatment for these lesions, particularly those that are surgically inaccessible. Because only complete AVM obliteration is believed to protect against the future risk of hemorrhage, identifying lesion characteristics that predict response to therapy is an important objective. The goal of this study is to evaluate the influence of angiographic features of AVMs on the rate of obliteration following treatment with SRS. METHODS This is a retrospective cohort study of pediatric patients (age ≤18 years) treated with Gamma Knife SRS for cerebral AVMs between 2000 and 2012. Detailed angiographic data at the time of initial angiographic evaluation were prospectively recorded by experienced neurointerventional radiologists. The primary outcome was the rate of obliteration on a 3-year follow-up angiogram. RESULTS We identified 42 pediatric patients treated with SRS for cerebral AVMs. Twenty-seven patients completed 3-year angiographic follow-ups. Complete obliteration was seen in 30%, partial response in 67%, and no response in 4%. Higher SRS dose was associated with complete obliteration. Larger AVM diameter, presence of multiple draining veins, and presence of multiple draining veins reaching a sinus were associated with partial response. In this small cohort, diffuse AVM borders, presence of aneurysm, and pre-SRS embolization were not associated with obliteration. CONCLUSIONS Our study identifies AVMs in the pediatric population with a nidus diameter of <2.5 cm and a solitary draining vein as the most likely to undergo complete obliteration after SRS treatment.
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Affiliation(s)
- Sunil A Sheth
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Blamek S, Larysz D, Miszczyk L. Stereotactic linac radiosurgery and hypofractionated stereotactic radiotherapy for pediatric arteriovenous malformations of the brain: experiences of a single institution. Childs Nerv Syst 2013; 29:651-6. [PMID: 23224360 PMCID: PMC3594818 DOI: 10.1007/s00381-012-1983-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 11/15/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of our study was to evaluate treatment results and toxicity of stereotactic irradiation for arteriovenous malformations (AVMs) in children. METHODS A group of ten consecutive children (four boys and six girls) irradiated between 2002 and 2010 at our institution was included into the study. The mean age at the time of treatment was 15.4 and ranged between 8 and 18 years. There were two Spetzler-Martin grade IV, four grade III, and four grade II lesions. Mean AVM volume was 13.2 cm(3) and varied from 0.6 to 36.8 cm(3). In five patients, the planned dose of 16-20 Gy was delivered in single fraction, in five the total dose of 16-24 Gy was delivered in two to three fractions. One patient was reirradiated with a dose of 15 Gy, 7 years after the initial treatment. RESULTS The median follow-up was 38.5 months. The treatment resulted in total obliteration in eight patients and partial in one. The median time to obliteration was 22 months; actuarial total obliteration rates were 20, 54, 54, and 83 % after 1, 2, 3, and 4 years of follow-up, respectively. No patient bled after the treatment. In one patient, new epileptic seizures developed after the treatment; in magnetic resonance imaging, focal necrosis was revealed. In five patients, asymptomatic imaging abnormalities were seen during follow-up. CONCLUSIONS Stereotactic radiotherapy appears to be an effective method of treatment for pediatric AVMs, the patients however require meticulous follow-up because of relative high incidence of radiation-induced imaging abnormalities.
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Affiliation(s)
- Sławomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland.
| | - Dawid Larysz
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland ,Department of Neurosurgery, Silesian University of Medicine, ul. Medyków 14, 40-752 Katowice, Poland
| | - Leszek Miszczyk
- Department of Radiotherapy, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, ul. Wybrzeże AK 15, 44-100 Gliwice, Poland
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Dinca EB, de Lacy P, Yianni J, Rowe J, Radatz MWR, Preotiuc-Pietro D, Kemeny AA. Gamma knife surgery for pediatric arteriovenous malformations: a 25-year retrospective study. J Neurosurg Pediatr 2012; 10:445-50. [PMID: 22938080 DOI: 10.3171/2012.8.peds1241] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present their 25-year experience in treating pediatric arteriovenous malformations (AVMs) to allow comparisons with other historic studies and data in adults. METHODS Data were collected from a prospectively maintained departmental database selected for age and supplemented by case note review and telephone interviews as appropriate. RESULTS Three hundred sixty-three patients, ages 1-16 years (mean ± SD, 12 ± 3.2 years), underwent 410 treatments; 4 had planned 2-stage treatments and 43 were retreated subsequent to an initial partial response. Fifty-eight percent received general anesthesia for the procedure. Sixteen percent had previously undergone embolization. The most common presenting symptoms were as follows: hemorrhage (80.2%), epilepsy (8.3%; overall seizure prevalence 19.9%), and migrainous headaches (6.3%). Only 0.28% of the AVMs were incidental findings. The mean lesion volume was 3.75 ± 5.3 cm3 (range 0.01-32.8 cm3), with a median Spetzler-Martin grade of III (range I-V). The mean peripheral (therapeutic) dose was 22.7 ± 2.3 Gy (range 15-25 Gy), corresponding to a mean maximum dose of 43.6 ± 6 Gy (range 25-51.4 Gy). The obliteration rate was 71.3% in patients who received one treatment and 62.5% for retreated patients, with a mean obliteration time of 32.4 and 79.6 months, respectively. The overall obliteration rate was 82.7%. No follow-up data are as yet available for the 4 patients who underwent the staged treatments. Only 4 patients received peripheral doses below 20 Gy, and the AVM was obliterated in 3 of these patients. The other patients received 20, 22.5, or 25 Gy and had obliteration rates of 82.6%, 77.7%, and 86.3%, respectively. The bleeding rate postradiosurgery was 2.2%, and the cumulative complication rate was 3.6%, with radionecrosis being the most common complication (1.1%). CONCLUSIONS Surprisingly, there was no correlation (p = 0.43) between outcome and radiosurgical dose when that dose was between 20 and 25 Gy, thus suggesting that the lower of these 2 doses may be effective. Radiosurgery for pediatric AVM is safe and effective.
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Affiliation(s)
- Eduard B Dinca
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
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25
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See AP, Raza S, Tamargo RJ, Lim M. Stereotactic radiosurgery of cranial arteriovenous malformations and dural arteriovenous fistulas. Neurosurg Clin N Am 2012; 23:133-46. [PMID: 22107864 DOI: 10.1016/j.nec.2011.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Cranial arteriovenous malformations (AVM) and cranial dural arteriovenous fistulas (AVF) carry a significant risk of morbidity and mortality when they hemorrhage. Current treatment options include surgery, embolization, radiosurgery, or a combination of these treatments. Radiosurgery is thought to reduce the risk hemorrhage in AVMs and AVFs by obliterating of the nidus of abnormal vasculature over the course of 2 to 3 years. Success in treating AVMs is variable depending on the volume of the lesion, the radiation dose, and the pattern of vascular supply and drainage. This article discusses the considerations for selecting radiosurgery as a treatment modality in patients who present with AVMs and AVFs.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, The Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
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