Gamma Knife surgery for arteriovenous malformations in children

Clinical article

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Object

The aim of this study was to evaluate the long-term imaging and clinical outcomes of intracranial arteriovenous malformations (AVMs) in children treated with Gamma Knife surgery (GKS).

Methods

Between 1989 and 2007, 200 patients with AVMs who were 18 years of age or younger were treated at the University of Virginia Health System. Excluding 14 patients who had not reached 2-year follow-up, 186 patients comprised this study. Hemorrhage was the most common presenting symptom leading to the diagnosis of AVMs (71.5%). The mean nidus volume was 3.2 cm3 at the time of GKS, and a mean prescription dose of 21.9 Gy was used.

Results

After initial GKS, 49.5% of patients achieved total angiographic obliteration. Forty-one patients whose AVM nidi remained patent underwent additional GKS. The obliteration rate increased to 58.6% after a second or multiple GKS. Subtotal obliteration was achieved in 9 patients (4.8%). Forty-nine patients (26.3%) still had a patent residual nidus. In 19 patients (10.2%), obliteration was confirmed on MR imaging only. Ten patients had 17 hemorrhages during the follow-up period. The hemorrhage rate was 5.4% within 2 years after GKS and 0.8% between 2 and 5 years. Six patients developed neurological deficits along with the radiation-induced changes. Two patients developed asymptomatic meningiomas 10 and 12 years after GKS. After a mean clinical follow-up of 98 months, less than 4% of patients had difficulty attending school or developing a career.

Conclusions

Gamma Knife surgery offers a reasonable chance of obliteration of an AVM in pediatric patients. The incidence of symptomatic radiation-induced changes is relatively low; however, long-term clinical and imaging follow-up is required to identify delayed cyst formation and secondary tumors.

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

Article Information

Address correspondence to: Jason Sheehan, M.D., Ph.D., Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, Virginia 22908. email: jsheehan@virginia.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Images obtained in a 13-year-old girl who presented with seizures leading to the diagnosis of AVM. The nidus is located at the left central area, measuring 27 × 17 × 21 mm. A: Gamma Knife surgery treatment plan. B and C: Left internal carotid artery injection angiograms obtained 2 years after GKS, showing complete obliteration of the nidus. The patient became seizure free.

  • View in gallery

    Angiograms obtained in a 4-year-old girl who presented with an intracerebral hemorrhage leading to the diagnosis of a right thalamic AVM measuring 20 × 20 × 12 mm. A–D: Right internal carotid artery and vertebral injection angiograms. The patient underwent GKS with a prescription dose of 21 Gy. E and F: The nidus was obliterated 2 years after GKS without adverse effects.

  • View in gallery

    Images obtained in an 11-year-old boy with an intracerebral hemorrhage that led to the diagnosis of a right thalamic AVM. A and B: Frontal and lateral projection angiograms. The patient underwent GKS with a prescription dose of 25 Gy. C: Four months after GKS, axial T2-weighted MR imaging revealed radiation-induced imaging changes. D and E: The changes continued to deteriorate 2 months later as noted on T2-weighted (D) and enhanced T1-weighted (E) MR images, and the patient presented with aggravated right hemiparesis. He was treated with corticosteroids. F and G: The AVM was obliterated 16 months after GKS as noted on anterior/posterior and lateral projection angiograms. H: A T2-weighted MR image obtained 40 months after GKS, revealing that the radiation-induced imaging changes had almost disappeared. I and J: Axial T2-weighted (I) and enhanced T1-weighted (J) MR images obtained 18 years after GKS, revealing a small area of encephalomalacia. The patient still had mild weakness in his right lower leg.

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