Stereotactic radiosurgery for arteriovenous malformations, Part 2: management of pediatric patients

Clinical article

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  • 1 Departments of Neurological Surgery and
  • 2 Radiation Oncology, and
  • 3 Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
  • 4 Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
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Object

The authors conducted a study to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for pediatric arteriovenous malformations (AVMs).

Methods

Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 135 patients were younger than 18 years of age. The median maximum diameter and target volumes were 2.0 cm (range 0.6–5.2 cm) and 2.5 cm3 (range 0.1–17.5 cm3), respectively. The median margin dose was 20 Gy (range 15–25 Gy).

Results

The actuarial rates of total obliteration documented by angiography or MR imaging at 71.3 months (range 6–264 months) were 45%, 64%, 67%, and 72% at 3, 4, 5, and 10 years, respectively. The median time to complete angiographically documented obliteration was 48.9 months. Of 81 patients with 4 or more years of follow-up, 57 patients (70%) had total obliteration documented by angiography. Factors associated with a higher rate of documented AVM obliteration were smaller AVM target volume, smaller maximum diameter, and larger margin dose. In 8 patients (6%) a hemorrhage occurred during the latency interval, and 1 patient died. The rates of AVM hemorrhage after SRS were 0%, 1.6%, 2.4%, 5.5%, and 10.0% at 1, 2, 3, 5, and 10 years, respectively. The overall annual hemorrhage rate was 1.8%. Larger volume AVMs were associated with a significantly higher risk of hemorrhage after SRS. Permanent neurological deficits due to adverse radiation effects developed in 2 patients (1.5%) after SRS, and in 1 patient (0.7%) delayed cyst formation occurred.

Conclusions

Stereotactic radiosurgery is a gradually effective and relatively safe management option for pediatric patients in whom surgery is considered to pose excessive risks. Although hemorrhage after AVM obliteration did not occur in the present series, patients remain at risk during the latency interval until obliteration is complete. The best candidates for SRS are pediatric patients with smaller volume AVMs located in critical brain regions.

Abbreviations used in this paper: ARE = adverse radiation effect; AVM = arteriovenous malformation; HR = hazard ratio; SRS = stereotactic radiosurgery.

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Contributor Notes

Address correspondence to: L. Dade Lunsford, M.D., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: lunsfordld@upmc.edu.

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.9.PEDS10458.

  • 1

    Al-Shahi R, , Bhattacharya JJ, , Currie DG, , Papanastassiou V, , Ritchie V, & Roberts RC, : Prospective, population-based detection of intracranial vascular malformations in adults: the Scottish Intracranial Vascular Malformation Study (SIVMS). Stroke 34:11631169, 2003

    • Search Google Scholar
    • Export Citation
  • 2

    Altschuler EM, , Lunsford LD, , Coffey RJ, , Bissonette DJ, & Flickinger JC: Gamma knife radiosurgery for intracranial arteriovenous malformations in childhood and adolescence. Pediatr Neurosci 15:5361, 1989

    • Search Google Scholar
    • Export Citation
  • 3

    ApSimon HT, , Reef H, , Phadke RV, & Popovic EA: A population-based study of brain arteriovenous malformation: long-term treatment outcomes. Stroke 33:27942800, 2002

    • Search Google Scholar
    • Export Citation
  • 4

    Brown RD Jr, , Wiebers DO, , Torner JC, & O'Fallon WM: Incidence and prevalence of intracranial vascular malformations in Olmsted County, Minnesota, 1965 to 1992. Neurology 46:949952, 1996

    • Search Google Scholar
    • Export Citation
  • 5

    Celli P, , Ferrante L, , Palma L, & Cavedon G: Cerebral arteriovenous malformations in children. Clinical features and outcome of treatment in children and in adults. Surg Neurol 22:4349, 1984

    • Search Google Scholar
    • Export Citation
  • 6

    Cohen-Gadol AA, & Pollock BE: Radiosurgery for arteriovenous malformations in children. J Neurosurg 104:6 Suppl 388391, 2006

  • 7

    da Costa L, , Wallace MC, , Ter Brugge KG, , O'Kelly C, , Willinsky RA, & Tymianski M: The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 40:100105, 2009

    • Search Google Scholar
    • Export Citation
  • 8

    Di Rocco C, , Tamburrini G, & Rollo M: Cerebral arteriovenous malformations in children. Acta Neurochir (Wien) 142:145158, 2000

  • 9

    Flickinger JC, , Kondziolka D, , Lunsford LD, , Kassam A, , Phuong LK, & Liscak R, : Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Int J Radiat Oncol Biol Phys 46:11431148, 2000

    • Search Google Scholar
    • Export Citation
  • 10

    Fullerton HJ, , Achrol AS, , Johnston SC, , McCulloch CE, , Higashida RT, & Lawton MT, : Long-term hemorrhage risk in children versus adults with brain arteriovenous malformations. Stroke 36:20992104, 2005

    • Search Google Scholar
    • Export Citation
  • 11

    Gerosa MA, , Cappellotto P, , Licata C, , Iraci G, , Pardatscher K, & Fiore DL: Cerebral arteriovenous malformations in children (56 cases). Childs Brain 8:356371, 1981

    • Search Google Scholar
    • Export Citation
  • 12

    Gobin YP, , Laurent A, , Merienne L, , Schlienger M, , Aymard A, & Houdart E, : Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85:1928, 1996

    • Search Google Scholar
    • Export Citation
  • 13

    Heros RC, , Korosue K, & Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570578, 1990

    • Search Google Scholar
    • Export Citation
  • 14

    Hillman J: Population-based analysis of arteriovenous malformation treatment. J Neurosurg 95:633637, 2001

  • 15

    Hladky JP, , Lejeune JP, , Blond S, , Pruvo JP, & Dhellemmes P: Cerebral arteriovenous malformations in children: report on 62 cases. Childs Nerv Syst 10:328333, 1994

    • Search Google Scholar
    • Export Citation
  • 16

    Karlsson B, , Lax I, & Söderman M: Risk for hemorrhage during the 2-year latency period following gamma knife radiosurgery for arteriovenous malformations. Int J Radiat Oncol Biol Phys 49:10451051, 2001

    • Search Google Scholar
    • Export Citation
  • 17

    Kihlström L, , Guo WY, , Karlsson B, , Lindquist C, & Lindqvist M: Magnetic resonance imaging of obliterated arteriovenous malformations up to 23 years after radiosurgery. J Neurosurg 86:589593, 1997

    • Search Google Scholar
    • Export Citation
  • 18

    Lawton MT, , Kim H, , McCulloch CE, , Mikhak B, & Young WL: A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery 66:702713, 2010

    • Search Google Scholar
    • Export Citation
  • 19

    Levy EI, , Niranjan A, , Thompson TP, , Scarrow AM, , Kondziolka D, & Flickinger JC, : Radiosurgery for childhood intracranial arteriovenous malformations. Neurosurgery 47:834842, 2000

    • Search Google Scholar
    • Export Citation
  • 20

    Lunsford LD, , Kondziolka D, , Flickinger JC, , Bissonette DJ, , Jungreis CA, & Maitz AH, : Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512524, 1991

    • Search Google Scholar
    • Export Citation
  • 21

    Maesawa S, , Flickinger JC, , Kondziolka D, & Lunsford LD: Repeated radiosurgery for incompletely obliterated arteriovenous malformations. J Neurosurg 92:961970, 2000

    • Search Google Scholar
    • Export Citation
  • 22

    Maruyama K, , Kawahara N, , Shin M, , Tago M, , Kishimoto J, & Kurita H, : The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med 352:146153, 2005

    • Search Google Scholar
    • Export Citation
  • 23

    Mast H, , Young WL, , Koennecke HC, , Sciacca RR, , Osipov A, & Pile-Spellman J, : Risk of spontaneous haemorrhage after diagnosis of cerebral arteriovenous malformation. Lancet 350:10651068, 1997

    • Search Google Scholar
    • Export Citation
  • 24

    Nataf F, , Schlienger M, , Lefkopoulos D, , Merienne L, , Ghossoub M, & Foulquier JN, : Radiosurgery of cerebral arteriovenous malformations in children: a series of 57 cases. Int J Radiat Oncol Biol Phys 57:184195, 2003

    • Search Google Scholar
    • Export Citation
  • 25

    Nicolato A, , Foroni R, , Seghedoni A, , Martines V, , Lupidi F, & Zampieri P, : Leksell gamma knife radiosurgery for cerebral arteriovenous malformations in pediatric patients. Childs Nerv Syst 21:301308, 2005

    • Search Google Scholar
    • Export Citation
  • 26

    Ogilvy CS, , Stieg PE, , Awad I, , Brown RD Jr, , Kondziolka D, & Rosenwasser R, : AHA Scientific Statement. Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 103:26442657, 2001

    • Search Google Scholar
    • Export Citation
  • 27

    Pan DH, , Kuo YH, , Guo WY, , Chung WY, , Wu HM, & Liu KD, : Gamma Knife surgery for cerebral arteriovenous malformations in children: a 13-year experience. J Neurosurg Pediatr 1:296304, 2008

    • Search Google Scholar
    • Export Citation
  • 28

    Paulsen RD, , Steinberg GK, , Norbash AM, , Marcellus ML, & Marks MP: Embolization of basal ganglia and thalamic arteriovenous malformations. Neurosurgery 44:991997, 1999

    • Search Google Scholar
    • Export Citation
  • 29

    Perini S, , Zampieri P, , Rosta L, , Piovan E, , Micheli ED, & Nicolato A, : Endovascular treatment of pial AVMs: technical options, indications and limits in pediatric age patients. J Neurosurg Sci 41:325330, 1997

    • Search Google Scholar
    • Export Citation
  • 30

    Pollock BE, & Brown RD Jr: Management of cysts arising after radiosurgery to treat intracranial arteriovenous malformations. Neurosurgery 49:259265, 2001

    • Search Google Scholar
    • Export Citation
  • 31

    Pollock BE, & Flickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:7985, 2002

  • 32

    Pollock BE, , Flickinger JC, , Lunsford LD, , Maitz A, & Kondziolka D: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42:12391247, 1998

    • Search Google Scholar
    • Export Citation
  • 33

    Pollock BE, , Kondziolka D, , Flickinger JC, , Patel AK, , Bissonette DJ, & Lunsford LD: Magnetic resonance imaging: an accurate method to evaluate arteriovenous malformations after stereotactic radiosurgery. J Neurosurg 85:10441049, 1996

    • Search Google Scholar
    • Export Citation
  • 34

    Reyns N, , Blond S, , Gauvrit JY, , Touzet G, , Coche B, & Pruvo JP, : Role of radiosurgery in the management of cerebral arteriovenous malformations in the pediatric age group: data from a 100-patient series. Neurosurgery 60:268276, 2007

    • Search Google Scholar
    • Export Citation
  • 35

    Shin M, , Kawamoto S, , Kurita H, , Tago M, , Sasaki T, & Morita A, : Retrospective analysis of a 10-year experience of stereotactic radio surgery for arteriovenous malformations in children and adolescents. J Neurosurg 97:779784, 2002

    • Search Google Scholar
    • Export Citation
  • 36

    Sinclair J, , Kelly ME, & Steinberg GK: Surgical management of posterior fossa arteriovenous malformations. Neurosurgery 58:4 Suppl 2 ONS-189ONS-201, 2006

    • Search Google Scholar
    • Export Citation
  • 37

    Smyth MD, , Sneed PK, , Ciricillo SF, , Edwards MS, , Wara WM, & Larson DA, : Stereotactic radiosurgery for pediatric intracranial arteriovenous malformations: the University of California at San Francisco experience. J Neurosurg 97:4855, 2002

    • Search Google Scholar
    • Export Citation
  • 38

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986

  • 39

    Stapf C, , Labovitz DL, , Sciacca RR, , Mast H, , Mohr JP, & Sacco RL: Incidence of adult brain arteriovenous malformation hemorrhage in a prospective population-based stroke survey. Cerebrovasc Dis 13:4346, 2002

    • Search Google Scholar
    • Export Citation
  • 40

    Stapf C, , Mast H, , Sciacca RR, , Choi JH, , Khaw AV, & Connolly ES, : Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 66:13501355, 2006

    • Search Google Scholar
    • Export Citation
  • 41

    Tanaka T, , Kobayashi T, , Kida Y, , Oyama H, & Niwa M: Comparison between adult and pediatric arteriovenous malformations treated by Gamma Knife radiosurgery. Stereotact Funct Neurosurg 66:Suppl 1 288295, 1996

    • Search Google Scholar
    • Export Citation
  • 42

    Wegner RE, , Oysul K, , Pollock BE, , Sirin S, , Kondziolka D, & Niranjan A, : A modified radiosurgery-based arteriovenous malformation grading scale and its correlation with outcomes. Int J Radiat Oncol Biol Phys 79:11471150, 2011

    • Search Google Scholar
    • Export Citation
  • 43

    Wilkins RH: Natural history of intracranial vascular malformations: a review. Neurosurgery 16:421430, 1985

  • 44

    Yamamoto M, , Jimbo M, , Hara M, , Saito I, & Mori K: Gamma knife radiosurgery for arteriovenous malformations: long-term follow-up results focusing on complications occurring more than 5 years after irradiation. Neurosurgery 38:906914, 1996

    • Search Google Scholar
    • Export Citation
  • 45

    Yen CP, , Monteith SJ, , Nguyen JH, , Rainey J, , Schlesinger DJ, & Sheehan JP: Gamma Knife surgery for arteriovenous malformations in children. Clinical article. J Neurosurg Pediatr 6:426434, 2010

    • Search Google Scholar
    • Export Citation
  • 46

    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 65:12061211, 2006

    • Search Google Scholar
    • Export Citation

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