Gamma Knife surgery for pediatric arteriovenous malformations: a 25-year retrospective study

Clinical article

Eduard B. Dinca M.D., Ph.D. 1 , 2 , Patricia de Lacy M.B.Ch.B., F.R.C.S.(SN) 2 , John Yianni M.D., F.R.C.S.(SN) 1 , 2 , Jeremy Rowe D.M., F.R.C.S.(SN) 1 , 2 , Matthias W. R. Radatz M.D., F.R.C.S. 1 , 2 , Daniel Preotiuc-Pietro M.Sc. 3 , and Andras A. Kemeny M.D., F.R.C.S. 1 , 2
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  • 1 National Centre for Stereotactic Radiosurgery;
  • 2 Department of Neurosurgery, Royal Hallamshire Hospital; and
  • 3 Department of Computer Science, University of Sheffield, United Kingdom
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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.

Abbreviations used in this paper:AVM = arteriovenous malformation; GKS = Gamma Knife surgery; SM = Spetzler-Martin.

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Contributor Notes

Address correspondence to: Andras A. Kemeny, M.D., National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom. email: aakemeny@gmail.com.

Please include this information when citing this paper: published online August 31, 2012; DOI: 10.3171/2012.8.PEDS1241.

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