Early obliteration of pediatric brain arteriovenous malformations after stereotactic radiosurgery: an international multicenter study

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  • 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;
  • 2 Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital;
  • 3 School of Medicine, National Yang-Ming University, Taipei, Taiwan;
  • 4 Department of Neurological Surgery, University of Pittsburgh, Pennsylvania;
  • 5 Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky;
  • 6 Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio;
  • 7 Department of Neurosurgery, New York University Langone Medical Center, New York, New York;
  • 8 Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada;
  • 9 Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan;
  • 10 Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico; and
  • 11 Department of Neurosurgery, University of Miami, Florida
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OBJECTIVE

Stereotactic radiosurgery (SRS) is a treatment option for pediatric brain arteriovenous malformations (AVMs), and early obliteration could encourage SRS utilization for a subset of particularly radiosensitive lesions. The objective of this study was to determine predictors of early obliteration after SRS for pediatric AVMs.

METHODS

The authors performed a retrospective review of the International Radiosurgery Research Foundation AVM database. Obliterated pediatric AVMs were sorted into early (obliteration ≤ 24 months after SRS) and late (obliteration > 24 months after SRS) responders. Predictors of early obliteration were identified, and the outcomes of each group were compared.

RESULTS

The overall study cohort was composed of 345 pediatric patients with obliterated AVMs. The early and late obliteration cohorts were made up of 95 (28%) and 250 (72%) patients, respectively. Independent predictors of early obliteration were female sex, a single SRS treatment, a higher margin dose, a higher isodose line, a deep AVM location, and a smaller AVM volume. The crude rate of post-SRS hemorrhage was 50% lower in the early (3.2%) than in the late (6.4%) obliteration cohorts, but this difference was not statistically significant (p = 0.248). The other outcomes of the early versus late obliteration cohorts were similar, with respect to symptomatic radiation-induced changes (RICs), cyst formation, and tumor formation.

CONCLUSIONS

Approximately one-quarter of pediatric AVMs that become obliterated after SRS will achieve this radiological endpoint within 24 months of initial SRS. The authors identified multiple factors associated with early obliteration, which may aid in prognostication and management. The overall risks of delayed hemorrhage, RICs, cyst formation, and tumor formation were not statistically different in patients with early versus late obliteration.

ABBREVIATIONS AVM = arteriovenous malformation; IRRF = International Radiosurgery Research Foundation; RBAS = radiosurgery-based AVM score; RIC = radiation-induced change; SM = Spetzler-Martin; SRS = stereotactic radiosurgery; VRAS = Virginia Radiosurgery AVM Scale.

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Contributor Notes

Correspondence Rebecca M. Burke: University of Virginia Health System, Charlottesville, VA. rmb8as@virginia.edu.

INCLUDE WHEN CITING Published online June 26, 2020; DOI: 10.3171/2020.4.PEDS19738.

Disclosures Dr. Grills reports < 5% stock ownership in and service on the executive board of directors of Greater Michigan Gamma Knife. Dr. Lunsford reports stock ownership in Elekta AB and being a consultant for Insightec and DSMB. Dr. Kondziolka reports funding from Brainlab for research support in brain tumor imaging (not related to this study).

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