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

Clinical article

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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.

Article Information

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.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Histograms detailing the distribution of patient age in years (left) and lesion volume (right). Frequency on the y axis refers to the number of patients.

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    Kaplan-Meyer curves showing the relationship between the time to radiological confirmation of obliteration and the percentage of patients with obliterated AVMs, for radiosurgical doses of 20, 22.5, and 25 Gy. There was no statistical difference among the doses (p = 0.35). The curves represent patients with complete follow-up data. Dotted line represents 25 Gy; dashed line, 22.5 Gy; and solid line, 20 Gy.

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