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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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Rodríguez Mallma MJ, Vilca-Aguilar M, Zuloaga-Rotta L, Borja-Rosales R, Salas-Ojeda M, Mauricio D. Machine Learning Approach for Analyzing 3-Year Outcomes of Patients with Brain Arteriovenous Malformation (AVM) after Stereotactic Radiosurgery (SRS). Diagnostics (Basel) 2023; 14:22. [PMID: 38201331 PMCID: PMC10871108 DOI: 10.3390/diagnostics14010022] [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: 11/29/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
A cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels that irregularly connects arteries and veins. Stereotactic radiosurgery (SRS) has been shown to be an effective treatment for AVM patients, but the factors associated with AVM obliteration remains a matter of debate. In this study, we aimed to develop a model that can predict whether patients with AVM will be cured 36 months after intervention by means of SRS and identify the most important predictors that explain the probability of being cured. A machine learning (ML) approach was applied using decision tree (DT) and logistic regression (LR) techniques on historical data (sociodemographic, clinical, treatment, angioarchitecture, and radiosurgery procedure) of 202 patients with AVM who underwent SRS at the Instituto de Radiocirugía del Perú (IRP) between 2005 and 2018. The LR model obtained the best results for predicting AVM cure with an accuracy of 0.92, sensitivity of 0.93, specificity of 0.89, and an area under the curve (AUC) of 0.98, which shows that ML models are suitable for predicting the prognosis of medical conditions such as AVM and can be a support tool for medical decision-making. In addition, several factors were identified that could explain whether patients with AVM would be cured at 36 months with the highest likelihood: the location of the AVM, the occupation of the patient, and the presence of hemorrhage.
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Affiliation(s)
| | - Marcos Vilca-Aguilar
- Instituto de Radiocirugía del Perú, Clínica San Pablo, Lima 15023, Peru
- Servicio de Neurocirugía, Hospital María Auxiliadora, Lima 15828, Peru
| | - Luis Zuloaga-Rotta
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | - Rubén Borja-Rosales
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | | | - David Mauricio
- Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
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3
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Luo FR, Zhou Y, Wang Z, Liu QY. Cerebral proliferative angiopathy in pediatric age presenting as neurological disorders: A case report. World J Clin Cases 2023; 11:8071-8077. [DOI: 10.12998/wjcc.v11.i33.8071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare subtype of arteriovenous malformation. It is extremely rare in pediatric patients and has serious implications for developing children. However, reports of these disorders worldwide are limited, and no uniform reference for diagnosis and treatment options exists. We report the case of a 6-year-old with CPA having predominantly neurological dysfunction and review the literature on pediatric CPA.
CASE SUMMARY We report the case of a pediatric patient with CPA analyzed using digital subtraction angiography (DSA) who presented initially with a neurological disorder as the main manifestation. This case is the basis for further discussion of the clinical presentation, pathogenesis, diagnosis, and treatment of CPA in children. After the cerebral DSA, the patient was treated conservatively with sedation, fluid replacement, and blood anticoagulation. She could not cooperate with the follow-up magnetic resonance imaging examination because of her young age, and her family declined further treatment because of the surgery’s high risk. She was followed up for 3 months; her symptoms did not worsen.
CONCLUSION This report of rare pediatric CPA can inform and advance clinical research on congenital cerebrovascular diseases.
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Affiliation(s)
- Fu-Ren Luo
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
| | - Ying Zhou
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Zhong Wang
- Department of Radiology, Mianyang Central Hospital, Mianyang 621000, Sichuan Province, China
| | - Qi-Yu Liu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, Sichuan Province, China
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4
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See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, 02115, Boston, MA, USA.
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5
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Tripathi M, Deora H, Tripathi S, Ballari N. Role of gamma knife radiosurgery in the management of intracranial pathologies of pediatric population: Current concepts, limitations, and future directions. J Pediatr Neurosci 2022. [DOI: 10.4103/jpn.jpn_51_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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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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7
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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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8
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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9
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Meling TR, Patet G. What is the best therapeutic approach to a pediatric patient with a deep-seated brain AVM? Neurosurg Rev 2019; 42:409-416. [PMID: 30980204 DOI: 10.1007/s10143-019-01101-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/27/2019] [Indexed: 11/25/2022]
Abstract
Although brain arteriovenous malformations (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous intracranial hemorrhages. Pediatric bAVMs tend to rupture more frequently and seem to have higher recurrence rates than bAVMs in adults. Thus, the management of pediatric bAVMs is particularly challenging. In general, the treatment options are conservative treatment, microsurgery, endovascular therapy (EVT), gamma knife radiosurgery (GKRS), proton-beam stereotactic radiosurgery (PSRS), or a combination of the above. In order to identify the best approach to deep-seated pediatric bAVMs, we performed a systematic review, according to the PRISMA guidelines. None of the options seem to offer a clear advantage over the others when used alone. Microsurgery provides the highest obliteration rate, but has higher incidence of neurological complications. EVT may play a role when used as adjuvant therapy, but as a stand-alone therapy, the efficacy is low and the long-term side effects of radiation from the multiple sessions required in deep-seated pediatric bAVMs are still unknown. GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population.
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Affiliation(s)
- Torstein R Meling
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.
| | - Gildas Patet
- Department of Clinical Neurosciences, Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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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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Hasegawa H, Hanakita S, Shin M, Kawashima M, Takahashi W, Ishikawa O, Koizumi S, Nakatomi H, Saito N. Comparison of the Long-term Efficacy and Safety of Gamma Knife Radiosurgery for Arteriovenous Malformations in Pediatric and Adult Patients. Neurol Med Chir (Tokyo) 2018; 58:231-239. [PMID: 29769453 PMCID: PMC6002683 DOI: 10.2176/nmc.st.2018-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is debated whether the efficacy and long-term safety of gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs) differs between adult and pediatric patients. We aimed to clarify the long-term outcomes of GKRS in pediatric patients and how they compare to those in adult patients. We collected data for 736 consecutive patients with AVMs treated with GKRS between 1990 and 2014 and divided the patients into pediatric (age < 20 years, n = 144) and adult (age ≥ 20 years, n = 592) cohorts. The mean follow-up period in the pediatric cohort was 130 months. Compared to the adult patients, the pediatric patients were significantly more likely to have a history of hemorrhage (P < 0.001). The actuarial rates of post-GKRS nidus obliteration in the pediatric cohort were 36%, 60%, and 87% at 2, 3, and 6 years, respectively. Nidus obliteration occurred earlier in the pediatric cohort than in the adult cohort (P = 0.015). The actuarial rates of post-GKRS hemorrhage in the pediatric cohort were 0.7%, 2.5%, and 2.5% at 1, 5, and 10 years, respectively. Post-GKRS hemorrhage was marginally less common in the pediatric cohort than in the adult cohort (P = 0.056). Cyst formation/encapsulated hematoma were detected in seven pediatric patients (4.9%) at a median post-GKRS timepoint of 111 months, which was not significantly different from the rate in the adult cohort. Compared to adult patients, pediatric patients experience earlier therapeutic effects from GKRS for AVMs, and this improves long-term outcomes.
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Affiliation(s)
| | | | - Masahiro Shin
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Osamu Ishikawa
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Nobuhito Saito
- Department of Neurosurgery, University of Tokyo Hospital
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12
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Nomoto AK, Shojima M, Nakatomi H, Saito N. Does Advanced Age Affect the Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformation? World Neurosurg 2017; 109:e715-e723. [PMID: 29066317 DOI: 10.1016/j.wneu.2017.10.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is generally considered a minimally invasive treatment modality. However, definitive evidence of the efficacy of SRS in the elderly population is still not available. METHODS The outcomes of 561 elderly and nonelderly patients who underwent SRS for AVM at our institution between 1990 and 2013 were reviewed, analyzed, and compared. Elderly patients were defined as those age ≥60 years at the time of SRS. RESULTS The elderly cohort comprised 55 patients; the nonelderly cohort, 506. In the elderly cohort, the median age was 65 years, and the duration of follow-up was 91 months. The actuarial obliteration rates were 47% at 3 years, 70% at 4 years, and 76% at 5 years in the elderly cohort, and 57% at 3 years, 76% at 4 years, and 83% at 5 years in the nonelderly cohort. In the elderly cohort, the hemorrhage rates during the post-SRS latent phase were 5.2%/year in patients with hemorrhagic onset and 0%/year in those with nonhemorrhagic onset, and event-free survival (EFS) was 93% at 6 years and 89% at 12 years. The obliteration rate, mortality, and EFS rate were not significantly different between the 2 cohorts, whereas the rate of perifocal edema was significantly lower (P = 0.021) in the elderly cohort. The pre-SRS and post-SRS hemorrhage rates were slightly higher in the elderly cohort, albeit without statistical significance. CONCLUSIONS Therapeutic effects and outcomes of SRS are similar in elderly and nonelderly patients. Treatment-related neurologic deficits are rare, and longer EFS can be expected.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Shunya Hanakita
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan; Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Akihiro K Nomoto
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
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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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Starke RM, Ding D, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery. J Neurosurg Pediatr 2017; 19:136-148. [PMID: 27911249 DOI: 10.3171/2016.9.peds16284] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8-17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5-35 Gy), and the mean follow-up was 92 months (range 12-266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.
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Affiliation(s)
- Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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