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Pepper J, Lamin S, Thomas A, Walsh AR, Rodrigues D, Lo WB, Solanki GA. Clinical features and outcome in pediatric arteriovenous malformation: institutional multimodality treatment. Childs Nerv Syst 2022; 39:975-982. [PMID: 36580118 DOI: 10.1007/s00381-022-05800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Intracranial arteriovenous-malformation (AVM) is a relatively rare condition in pediatrics, yet is a major cause of spontaneous intracranial hemorrhage with a risk of fatal hemorrhage reported to be between 4 and 29%. Little is known about vessel morphology and optimum treatment modalities including multimodality combination therapy and prognosis in children. METHODS A retrospective review of all children presenting to our institution from 2006 to 2020 that had an AVM was undertaken. RESULTS A total of 50 children were identified with median age of 11 (range 1-16) years. The mean follow-up was 7.6 years. Forty-one children presented as an emergency and of those, 40 had hemorrhage identified on initial brain imaging. The average nidus size was 25 mm, drainage was superficial in 51% of cases, and located in eloquent cortex in 56%. The supplemental Spetzler-Martin grading indicated 78% (39/50) were grade 4 and above (moderate to high risk). Primary treatment modalities included embolization in 50% (25) or SRS in 30% (15) and surgery in 20% (10).The AVM was obliterated on follow-up DSA in 66% children. Three children had post-treatment hemorrhage, two related to embolization and one the day following SRS, giving a re-bleed rate of 6%. The GOSE was available for 32 children at long term follow and 94% had a good outcome (GOSE 5-8). Two children died due to acute hemorrhage (4%). CONCLUSION The majority of children with AVM present with hemorrhage. The rebleed rate during definitive treatment is low at 6% over the study period. The selective use of the 3 modalities of treatment has significantly reduced mortality and severe disability.
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Affiliation(s)
- Joshua Pepper
- Birmingham Women's & Children's Hospital, Birmingham, UK.
| | - Saleh Lamin
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Allan Thomas
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | | | | | - William B Lo
- Birmingham Women's & Children's Hospital, Birmingham, UK
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2
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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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3
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Glazener EM, Lodin K, Miller MJ, Frager MJ, Rahimian J, Chen JC, Girvigian MR. Pediatric Intracranial Arteriovenous Malformation: Long-Term Outcomes with Linear Accelerator (LINAC)-Based Radiosurgery. Adv Radiat Oncol 2020; 5:850-855. [PMID: 33089017 PMCID: PMC7560570 DOI: 10.1016/j.adro.2020.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/28/2020] [Accepted: 03/19/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To analyze and report the long-term outcomes of intracranial arteriovenous malformations (AVM) treated with linear accelerator (LINAC)-based radiosurgery (LBRS) in the pediatric population. Methods and Materials A series of 34 pediatric patients (≤18 years old) who were treated between 2002 and 2016 were analyzed. All patients were treated with LBRS in a single fraction, with a median dose of 16.8 Gy to the 80% isodose line. Median age at treatment was 14.4 years (range 5.5-18.9). Median AVM volume was 2.91 mL (range 0.228-27.313). Median modified radiosurgery-based AVM score was 0.83 (range 0.18-2.96). The most common presenting symptom was intracranial hemorrhage (ICH) (n = 22, 64.7%). Nine patients underwent intervention before LBRS, which included prior embolization or resection. Seven lesions were in eloquent locations, defined as basal ganglia, thalamus, or brainstem. Cerebral angiography was done to confirm obliteration. Results Median follow-up time was 98 months (range 36-200 months). Twenty-two of the 34 lesions were obliterated (64.7%) with median time to obliteration of 37 months (range 14-79). No deaths occurred during the follow up period; however, two patients experienced ICH after treatment. Three other patients were treated for symptomatic radiation necrosis. Conclusions Treatment of intracranial AVM with LBRS in the pediatric population is demonstrated to be safe and effective with long-term follow up.
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4
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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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5
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Ilyas A, Chen CJ, Ding D, Buell TJ, Lee CC, Sheehan JP. In Reply: Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations. Neurosurgery 2018; 82:E77-E78. [PMID: 29294125 DOI: 10.1093/neuros/nyx599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] 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
| | - Cheng-Chia Lee
- Department of Neurological Surgery Taipei Veterans General Hospital Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia
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6
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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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7
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Thenier-Villa JL, Galárraga-Campoverde RA, Martínez Rolán RM, De La Lama Zaragoza AR, Martínez Cueto P, Muñoz Garzón V, Salgado Fernández M, Conde Alonso C. Linear Accelerator Stereotactic Radiosurgery of Central Nervous System Arteriovenous Malformations: A 15-Year Analysis of Outcome-Related Factors in a Single Tertiary Center. World Neurosurg 2017; 103:291-302. [PMID: 28435119 DOI: 10.1016/j.wneu.2017.04.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Linear accelerator stereotactic radiosurgery is one of the modalities available for the treatment of central nervous system arteriovenous malformations (AVMs). The aim of this study was to describe our 15-year experience with this technique in a single tertiary center and the analysis of outcome-related factors. METHODS From 1998 to 2013, 195 patients were treated with linear accelerator-based radiosurgery; we conducted a retrospective study collecting patient- and AVM-related variables. Treatment outcomes were obliteration, posttreatment hemorrhage, symptomatic radiation-induced changes, and 3-year neurologic status. We also analyzed prognostic factors of each outcome and predictability analysis of 5 scales: Spetzler-Martin grade, Lawton-Young supplementary and Lawton combined scores, radiosurgery-based AVM score, Virginia Radiosurgery AVM Scale, and Heidelberg score. RESULTS Overall obliteration rate was 81%. Nidus diameter and venous drainage were predictive of obliteration (P < 0.05), ruptured status and previous embolization were not related to rate of obliteration, and low-grade AVMs had higher obliteration rates. Posttreatment hemorrhage incidence was 8.72%; nidus diameter was the only predictor (P = 0.05). Symptomatic radiation-induced changes occurred in 11.79% of patients and were significantly associated with unruptured status (P < 0.05). Treatment success as a composite measure was obtained in 70.77% of patients. Receiver operating characteristic curves were presented for each scoring system and outcome measure; best area under the curve was 0.687 for Lawton combined score in the obliteration outcome. CONCLUSIONS In the long-term, linear accelerator-based radiosurgery is a useful, valid, effective, and safe modality for treatment of brain AVMs.
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Affiliation(s)
- José Luis Thenier-Villa
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain.
| | | | - Rosa María Martínez Rolán
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | | | - Pedro Martínez Cueto
- Department of Neuroradiology, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | - Víctor Muñoz Garzón
- Department of Radiation Oncology, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Manuel Salgado Fernández
- Department of Radiophysics, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
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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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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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10
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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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11
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Venerdì 3 Ottobre. Neuroradiol J 2014. [DOI: 10.1177/197140091402700507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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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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13
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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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14
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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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15
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Gross BA, Ropper AE, Du R. Vascular complications of stereotactic radiosurgery for arteriovenous malformations. Clin Neurol Neurosurg 2012; 115:713-7. [PMID: 22910397 DOI: 10.1016/j.clineuro.2012.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/16/2012] [Accepted: 08/05/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience. METHODS Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies. RESULTS After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage. CONCLUSION While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States
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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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Niazi TN, Klimo P, Anderson RCE, Raffel C. Diagnosis and management of arteriovenous malformations in children. Neurosurg Clin N Am 2011; 21:443-56. [PMID: 20561494 DOI: 10.1016/j.nec.2010.03.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arteriovenous malformation (AVM) is the most common cause of spontaneous intraparenchymal hemorrhage in children, excluding hemorrhages of prematurity and early infancy. Because most children diagnosed with an AVM undergo initial treatment emergently, the natural history of AVMs in the pediatric population is not well understood. Most pediatric AVMs do not come to clinical attention unless they hemorrhage. Therefore, their optimal management remains controversial. Children with intracranial AVMs represent a special challenge in that they harbor unacceptable lifelong risks of hemorrhage and potential neurologic deficits. Patients should be evaluated on a case-by-case basis to determine the best multidisciplinary treatment regimen that can be used to preserve neurologic function and eradicate the AVM with the lowest risk of mortality. Successful treatment depends on the location and size of the AVM, its hemodynamic properties, the clinical condition of the patient, and the treatment modality selected. The armamentarium for AVM management has grown with technological advances and now includes microsurgical resection, endovascular embolization, radiosurgery, or any combination of these modalities. Microsurgical resection remains the gold standard for treatment of accessible pediatric AVMs, especially in cases that present with intracranial hemorrhage. Newer modalities, such as embolization and radiosurgery, have provided additional tools to help children with large or deep-seated lesions that would be deemed unresectable with microsurgical techniques alone. Long-term follow-up with repeated diagnostic imaging is important despite complete obliteration of the lesion to rule out the small possibility of AVM recurrence.
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Affiliation(s)
- Toba N Niazi
- Department of Neurosurgery, Primary Children's Medical Center, University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT, USA
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Taylor ML, McDermott LN, Johnston PN, Haynes M, Ackerly T, Kron T, Franich RD. Stereotactic fields shaped with a micro-multileaf collimator: systematic characterization of peripheral dose. Phys Med Biol 2010; 55:873-81. [DOI: 10.1088/0031-9155/55/3/021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Ganz JC, Reda WA, Abdelkarim K. Adverse radiation effects after Gamma Knife Surgery in relation to dose and volume. Acta Neurochir (Wien) 2009; 151:9-19. [PMID: 19129961 DOI: 10.1007/s00701-008-0174-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Accepted: 09/17/2008] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The relationship between target volume and adverse radiation effects (AREs) at low prescription doses requires elucidation. The development of AREs in three series of patients treated in the Gamma Knife is analysed in relation to prescription dose and target volume. MATERIALS AND METHODS There were three groups. In group 1, there were of 275 patients with meningiomas; in group 2, 132 patients with vestibular schwannomas; and in group 3, 107 patients with arteriovenous malformations (AVMs). The minimum follow-up for each group was more than 24 months. All patients were followed up at six monthly intervals. The patients with tumours received a prescription dose of 12 Gy, which was varied to protect normal structures but not in relation to tumour volume per se. The desired AVM prescription dose was 25 Gy, but this was also reduced to protect normal structures and to keep the total dose within certain pre-defined limits. All AREs refer to intra-parenchymal increased perilesional T2 signal on MR irrespective of clinical correlation. RESULTS There was no relationship between tumour volume and the development of ARE in the tumour groups. There was a highly significant relationship between target volume and the development of ARE for the AVMs with their much higher dose. Radiation-induced clinical trigeminal and facial nerve deficits with both vestibular schwannomas and meningiomas were always associated with an increased T2 signal in the neighbouring brainstem parenchyma. CONCLUSIONS The relationship between target volume and the risk of adverse radiation effects may not apply with lower prescription doses. Individual radiosensitivity may explain why a minority suffer AREs unrelated to target volume. It is possible that radiation-induced brainstem parenchymal damage with concomitant cranial nerve deficits may be commoner after radiosurgery than is usually thought. If tumour control with lower doses is adequate, radiosurgery could be safely considered for larger targets associated with a high risk from microsurgery.
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Affiliation(s)
- J C Ganz
- Gamma Knife Center Cairo, Nasser Institute Shobra, Cairo, Egypt.
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Pan DHC, Kuo YH, Guo WY, Chung WY, Wu HM, Liu KD, Chang YC, Wang LW, Wong TT. Gamma Knife surgery for cerebral arteriovenous malformations in children: a 13-year experience. J Neurosurg Pediatr 2008; 1:296-304. [PMID: 18377305 DOI: 10.3171/ped/2008/1/4/296] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Studies on the efficacy of arteriovenous malformation (AVM) radiosurgery have largely been conducted in the adult population. Clinically, the results may not always be applicable to pediatric patients. Moreover, studies involving the pediatric population have largely comprised small- (< 3 cm3) and medium-sized (3-10 cm3) AVMs. For large (> 10 cm3) AVMs in children, sparse radiosurgical results are available. The current study was conducted to further clarify the role of radiosurgery in the treatment of pediatric AVMs. METHODS A retrospective analysis was performed of data obtained in 105 pediatric patients (< 18 years of age) with cerebral AVMs treated by Gamma Knife surgery (GKS) between 1993 and 2006. For statistical comparison the authors studied data acquired in 458 adult patients with AVMs treated during the same period. The patients underwent follow-up magnetic resonance imaging at 6-month intervals. Cerebral angiography was used to confirm the obliteration of the AVM. RESULTS In pediatric patients, the AVM obliteration rate at 48 months after a primary GKS was 65%. Repeated GKS in those in whom primary treatments failed further ablated some AVMs, for an overall obliteration rate of 81%. The efficacy of GKS correlated with the size of the AVM: 91% for small, 86% for medium, and 64% for large AVMs. The treatments were associated with an 8% morbidity rate and < 1% mortality rate. Posttreatment hemorrhage occurred in 4 (4%) of 105 patients. Obliteration rates at 48 months of small and extremely large (> 20 cm3) AVMs were similar in the pediatric and adult groups, whereas AVMs between 3 and 10 cm3 responded less efficaciously in children (p = 0.042). The AVMs with volumes ranging from 10 to 20 cm3 were also associated with a lower obliteration rate in children at 48 months, but statistical significance was not reached (p = 0.279). CONCLUSIONS Gamma Knife surgery is an effective and safe treatment alternative for pediatric AVMs. The medium (3-10-cm3) and large (10-20-cm3) AVMs tend to respond less efficaciously than those of comparable size in adults.
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Affiliation(s)
- David Hung-Chi Pan
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.
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21
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Buis DR, Dirven CMF, Lagerwaard FJ, Mandl ES, Lycklama A Nijeholt GJ, Eshghi DS, van den Berg R, Baayen JC, Meijer OWM, Slotman BJ, Vandertop WP. Radiosurgery of brain arteriovenous malformations in children. J Neurol 2008; 255:551-60. [PMID: 18283398 DOI: 10.1007/s00415-008-0739-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 07/31/2007] [Accepted: 09/05/2007] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- D R Buis
- Dept. of Neurosurgery, Neurosurgical Center Amsterdam, VU University Medical Center, 2F-005, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Kiran NAS, Kale SS, Vaishya S, Kasliwal MK, Gupta A, Sharma MS, Sharma BS, Mahapatra AK. Gamma Knife surgery for intracranial arteriovenous malformations in children: a retrospective study in 103 patients. J Neurosurg 2008; 107:479-84. [PMID: 18154017 DOI: 10.3171/ped-07/12/479] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This retrospective study was designed to study the outcome in children with intracranial arteriovenous malformations (AVMs) treated with Gamma Knife surgery (GKS). METHODS One hundred and forty-two children were treated with GKS at the authors' institution between April 1997 and March 2006; of these, 103 patients with a mean follow-up of 26.4 months (range 6-96 months) were included. The mean age at presentation was 13.9 years (range 3-18 years). Eighty-six (83%) patients presented with hemorrhage. In 57 children the AVMs were Spetzler-Martin Grade I or II, and in 46 the AVMs were Grades III, IV, or V. The mean volume of the AVMs was 2.4 ml (range 0.04-23.3 ml). The mean marginal dose administered was 24.4 Gy (range 15-27 Gy). Follow-up angiography was advised at 2 years after GKS and yearly thereafter. In patients with residual AVMs, follow-up angiography was advised yearly until 4 years after GKS. If residual AVM was present, even on a follow-up angiogram obtained 4 years postsurgery, the GKS was considered a failure. RESULTS Complete obliteration of the AVM was documented in 34 (87%) of the 39 patients with complete angiographic follow-up. The 3- and 4-year actuarial rates of nidus obliteration were 66 and 86% respectively. Three patients (2.9%) experienced bleeding during the latency period, and symptomatic radiation-induced edema was noted in four patients (3.8%). A significantly higher incidence of radiation edema was noted in patients with AVM volumes greater than 3 ml and in patients with Spetzler-Martin Grade IV and V AVMs. CONCLUSIONS Gamma Knife radiosurgery is an effective modality for the treatment of intracranial AVMs in children, yielding high obliteration rates and low complication rates.
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Reyns N, Blond S, Gauvrit JY, Touzet G, Coche B, Pruvo JP, Dhellemmes P. ROLE OF RADIOSURGERY IN THE MANAGEMENT OF CEREBRAL ARTERIOVENOUS MALFORMATIONS IN THE PEDIATRIC AGE GROUP. Neurosurgery 2007; 60:268-76; discussion 276. [PMID: 17290177 DOI: 10.1227/01.neu.0000249277.72063.bd] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To assess the safety and efficacy of radiosurgery for the management of arteriovenous malformations (AVMs) in the pediatric age group.
METHODS
We reviewed data from 100 children (44 girls and 56 boys) presenting a total of 103 AVMs treated by linear accelerator radiosurgery between December 1988 and May 2002. The median patient age was 12 years (range, 2–16 yr). Sixty-seven AVMs (65%) were in functional locations and 30% were inoperable. The mean AVM volume was 2.8 cm3 (range, 0.9–21.3 cm3). The mean marginal dose was 23 Gy (range, 15–25 Gy) and required between one and four isocenters. Fifty patients received multimodal treatments with embolization and/or surgery before and/or after radiosurgery. Given that 16 patients underwent two sessions of radiosurgery and one patient received three sessions, a total of 119 radiosurgical treatments were delivered. We maintained our clinical and angiographic follow-up for at least 36 months after irradiation or until the complete obliteration of the AVM was confirmed by angiography (our sole end point for judging clinical efficacy). Univariate and multivariate analysis were performed to determine predictive factors for obliteration.
RESULTS
Complete obliteration was achieved for 72 AVMs (70%). The permanent neurological deficit rate was 5%. One patient died because of rebleeding. None of our patients presented bleeding after an angiographically verified AVM obliteration. The main predictive factors for obliteration were low AVM volume and no previous embolization. Moreover, the younger the patient, the more effective the radiosurgery seemed to be.
CONCLUSION
Radiosurgery is a safe and effective treatment for AVMs in the pediatric age group. One criterion for success was the use of a prescription dose similar to that used with adult populations.
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Affiliation(s)
- Nicolas Reyns
- Department of Neurosurgery, University Hospital, Lille, France.
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Bristol RE, Albuquerque FC, Spetzler RF, Rekate HL, McDougall CG, Zabramski JM. Surgical management of arteriovenous malformations in children. J Neurosurg 2006; 105:88-93. [PMID: 16922068 DOI: 10.3171/ped.2006.105.2.88] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Children compose 3 to 20% of the patients with arteriovenous malformations (AVMs); however, AVMs are responsible for 30 to 50% of intracranial hemorrhages in children. METHODS The medical records of 82 children with 84 AVMs treated surgically between 1983 and 2005 were reviewed. Fifty-two patients (63%) presented with hemorrhage, 13.4% presented with seizures, and AVMs in 12% were found incidentally. Patients with brainstem lesions presented at a significantly younger age (p = 0.002) than those harboring lesions in other locations. Frontal lobe lesions were significantly smaller than those in other locations, and thalamic lesions were significantly larger (p = 0.012 and 0.005, respectively). Most patients with Spetzler-Martin Grades I to III lesions underwent craniotomy only. Half of the patients with Grade IV and V lesions underwent embolization, craniotomy, and radiosurgery. The mean follow-up period was 43 months. Postoperatively, the initial obliteration rate was 65%, with a long-term obliteration rate of 90%. The perioperative mortality rate was 3.7%. Altogether, 81% of patients had excellent outcomes, and patients with Grade I lesions had the best outcomes. Of the 52 patients who presented with hemorrhage, 17% had fair or poor outcomes. The recurrence rate was 5.6%. CONCLUSIONS Children with AVMs may be more prone than adults to present with a hemorrhage and to experience recurrence of the lesion after treatment. The authors favor resection for most AVMs in children and use embolization as a preoperative strategy for Grades II to V lesions treated surgically. Prehemorrhagic Grade IV and V lesions may best be treated conservatively and observed carefully for the development of symptoms. Long-term follow up of all patients is essential.
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Affiliation(s)
- Ruth E Bristol
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Zabel-du Bois A, Milker-Zabel S, Huber P, Schlegel W, Debus J. Pediatric cerebral arteriovenous malformations: The role of stereotactic linac-based radiosurgery. Int J Radiat Oncol Biol Phys 2006; 65:1206-11. [PMID: 16682140 DOI: 10.1016/j.ijrobp.2006.01.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 01/24/2006] [Accepted: 01/24/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate retrospectively clinical outcome and obliteration rates after linac-based radiosurgery (RS) in children with cerebral arteriovenous malformations (AVM). METHODS AND MATERIALS Between 1996 and 2002, 22 children with cerebral AVM were treated at our institution. Mean age at treatment was 11.8 years (range, 4.4-16.4 years). Classification according to Spetzler-Martin was 1 child grade I (4%), 7 grade II (32%), 12 grade III (56%), 1 grade IV (4%), and 1 grade V (4%). Median single dose was 18 Gy/80%-isodose. Median AVM volume was 4.2 mL (range, 0.4-26.5 mL). Median RS-based AVM-score was 1.07 (range, 0.61-3.55). Fifty-nine percent of children experienced intracranial hemorrhage before RS. Median follow-up was 3.1 years (range, 1.7-7.3 years). RESULTS Actuarial complete obliteration rate (CO) was 54% after 3 years and 65% after 4 years, respectively. Median time interval to CO was 27.1 months. Intracranial hemorrhage after RS was seen in five children after median 13.9 months. Annual bleeding risk was 9.1% after 1 year and 13.6% after 2 years. Maximum diameter>or=3 cm and AVM-volume>or=6 mL were significant predictors for intracranial hemorrhage. Neurologic deficits were improved/completely dissolved in 58% of children and remained stable in 42%. No new onset of neurologic dysfunction was seen after RS. CONCLUSIONS RS is safe and effective in pediatric cerebral AVM with high obliteration rates. Size and volume of AVM are significant predictors for intracranial bleeding. The same treatment guidelines as in adults should be applied. Careful long-term follow-up observation is required after RS from long life expectation.
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Affiliation(s)
- Angelika Zabel-du Bois
- Department of Radiotherapy, German Cancer Research Center, and Department of RadioOncology, University of Heidelberg, Heidelberg, Germany.
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Blount JP, Tubbs RS, Oakes WJ, Humphreys RP. History of surgery for cerebrovascular disease in children. Part III. Arteriovenous malformations. Neurosurg Focus 2006. [DOI: 10.3171/foc.2006.20.6.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Arteriovenous malformations (AVMs) are the most common cause of intracerebral hemorrhage in children. In this paper the authors trace the historical evolution of the recognition, diagnosis, and treatment of pediatric intracerebral AVMs, and they summarize the contemporary approach and current controversies surrounding treatment of these lesions. Important distinctions between adult and pediatric AVMs are emphasized.
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Affiliation(s)
| | | | | | - Robin P. Humphreys
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham/Children's Hospital of Alabama, Birmingham, Alabama; and the Hospital for Sick Children, University of Toronto, Ontario, Canada
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