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

Clinical article

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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.

Article Information

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.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Upper: Kaplan-Meier curves with corrected time (solid line) and uncorrected Kaplan-Meier curves with uncorrected time (broken line) for total obliteration by MR imaging or angiography after radiosurgery for pediatric AVMs. Lower: Kaplan-Meier curves with corrected time (solid line) and uncorrected Kaplan-Meier curves with uncorrected time (broken line) for total obliteration documented on angiography alone after radiosurgery for pediatric AVMs.

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    Kaplan-Meier curves for total obliteration documented on angiography after SRS for pediatric AVMs with a margin dose of ≥ 20 Gy vs < 20 Gy. A margin dose of ≥ 20 Gy was significantly associated with a higher total obliteration rate on angiography (p < 0.0005).

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    Kaplan-Meier curves showing the bleeding rate after SRS for pediatric AVMs.

  • View in gallery

    Studies obtained in a 12-year-old girl. A: Anterior and lateral vertebral artery (VA) angiograms documenting the left occipital AVM at the time of SRS. B: Anterior and lateral VA angiograms acquired 30 months after initial SRS, showing the absence of a nidus in the SRS field, but a small nidus was discovered outside the SRS field. This new nidus was treated by the second SRS. C: Anterior and lateral VA angiograms obtained 4 years after the second SRS, showing the absence of all nidi.

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