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

Kano, Hideyuki; Kondziolka, Douglas; Flickinger, John C.; Yang, Huai‐Che; Flannery, Thomas; Awan, Nasir; Niranjan, Ajay; Novotný, Josef; Lunsford, L. Dade

doi:10.3171/2011.9.peds10458

Cited by 97 publications

(69 citation statements)

References 53 publications

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“…31 The therapeutic outcomes were relatively homogeneous among the reports, and the associated neurological deficits were minimal (Table 6). 3,15,31,33,39,44 Regarding multidisciplinary treatment, the one reason that there was no difference between the SRS-only group and the combined treatment group in terms of treatment outcomes can be attributable to this study being a retrospective analysis looking at whether treatment options other than SRS were applied or not, depending on careful consideration of the patient situation, such as existence of hematoma, location of the lesions, accompanying aneurysms, and high-flow shunts. Further, the limitations of this study include the lack of statistical power due to a small patient population.…”

Section: Discussionmentioning

confidence: 99%

The long-term outcomes of radiosurgery for arteriovenous malformations in pediatric and adolescent populations

Hanakita¹,

Koga²,

Shin³

et al. 2015

PED

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OBJECT Although stereotactic radiosurgery (SRS) has been accepted as a therapeutic option for arteriovenous malformations (AVMs) in children and adolescents, substantial data are still lacking regarding the outcomes of SRS for AVMs in this age group, especially long-term complications. This study aimed to clarify the long-term outcomes of SRS for the treatment of AVM in pediatric patients aged ≤ 18 years. METHODS Outcomes of 116 patients who were aged 4–18 years when they underwent SRS between 1990 and 2009 at the study institute were analyzed retrospectively. RESULTS The median follow-up period after SRS was 100 months, with 6 patients followed up for more than 20 years. Actuarial obliteration rates at 3 and 5 years after SRS were 68% and 88%, respectively. Five hemorrhages occurred in 851 patient-years of follow-up. The annual bleeding rate after SRS before obliteration was calculated as 1.3%, which decreased to 0.2% after obliteration. Shorter maximum nidus diameter (p = 0.02) and higher margin dose (p = 0.03) were associated with a higher obliteration rate. Ten patients experienced adverse events after SRS. Of them, 4 patients presented with delayed complications years after SRS (range 9–20 years after SRS). CONCLUSIONS SRS can reduce the risk of hemorrhage in pediatric and adolescent AVMs, with an acceptable risk of complications in the long term. However, adverse events such as expanding hematoma and radiation necrosis that can occur after substantial follow-up should be taken into account at the time that treatment decisions are made and informed consent is obtained.

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Section: Discussionmentioning

confidence: 99%

The long-term outcomes of radiosurgery for arteriovenous malformations in pediatric and adolescent populations

Hanakita¹,

Koga²,

Shin³

et al. 2015

PED

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“…40 The use of MRI as the sole modality to document obliteration has been reported by authors from another tertiary radiosurgery referral center in a large recent series of radiosurgery in AVMs . [19][20][21][22][23][24] As to the AVMs that received preradiosurgery embolization in the present study, we do not have specific information regarding the goal of embolization in each case, nor do we know if the goal of embolization was achieved in each case. The lack of these data may affect our perspective on the role of embolization in the management of AVMs, especially in relation to radiosurgery.…”

Section: Study Limitationsmentioning

confidence: 99%

Radiosurgery for ruptured intracranial arteriovenous malformations

Ding¹,

Yen²,

Starke³

et al. 2014

JNS

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Object Ruptured intracranial arteriovenous malformations (AVMs) are at a significantly greater risk for future hemorrhage than unruptured lesions, thereby necessitating treatment in the majority of cases. In a retrospective, single-center study, the authors describe the outcomes after radiosurgery in a large cohort of patients with ruptured AVMs. Methods From an institutional review board–approved, prospectively collected AVM radiosurgery database, the authors identified all patients with a history of AVM rupture. They analyzed obliteration rates in all patients in whom radiological follow-up data were available (n = 639). However, to account for the latency period associated with radiosurgery, only those patients with more than 2 years of radiological follow-up and those with earlier AMV obliteration were included in the analysis of prognostic factors related to obliteration and complications. This resulted in a cohort of 565 patients with ruptured AVMs for whom data were analyzed; these patients had a median radiological follow-up of 57 months and a median age of 29 years. Twenty-one percent of the patients underwent preradiosurgery embolization. The median volume and prescription dose were 2.1 cm3 and 22 Gy, respectively. The Spetzler-Martin grade was III or higher in 56% of patients, the median radiosurgery-based AVM score was 1.08, and the Virginia Radiosurgery AVM Scale (RAS) score was 3 to 4 points in 44%. Survival and regression analyses were performed to determine obliteration rates over time and predictors of obliteration and complications. Results In the overall population of 639 patients with ruptured AVMs, the obliteration rate was 11.1% based on MRI only (71 of 639 patients), 56.0% based on angiography (358 of 639), and 67.1% based on combined modalities (429 of 639 patients). In the cohort of patients with 2 years of follow-up or an earlier AVM obliteration, the cumulative obliteration rate was 76% and the actuarial obliteration rates were 41% and 64% at 3 and 5 years, respectively. Multivariate analysis identified the absence of preradiosurgery embolization (p < 0.001), increased prescription dose (p = 0.001), the presence of a single draining vein (p = 0.046), no postradiosurgery-related hemorrhage (p = 0.007), and lower Virginia RAS score (p = 0.020) as independent predictors of obliteration. The annual risk of a hemorrhage occurring during the latency period was 2.0% and the rate of hemorrhage-related morbidity and mortality was 1.6%. Multivariate analysis showed that decreased prescription dose (p < 0.001) and multiple draining veins (p = 0.003) were independent predictors of postradiosurgery hemorrhage. The rates of symptomatic and permanent radiation-induced changes were 8% and 2.7%, respectively. In the multivariate analysis, a single draining vein (p < 0.001) and higher Virginia RAS score (p = 0.005) were independent predictors of radiation-induced changes following radiosurgery. Conclusions Radiosurgery effectively treats ruptured AVMs with an acceptably low risk-to-benefit ratio. For patients with ruptured AVMs, favorable outcomes are more likely when preradiosurgical embolization is avoided and a higher prescription dose can be delivered.

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“…[7][8][9][10][11][12] It is characterized by high obliteration rates, especially in small lesions, and low risk of adverse effects and complications. In the present retrospective study, we were not able to demonstrate an association of the optimal K index dose with improved obliteration rates, in comparison with smaller doses.…”

Section: Discussionmentioning

confidence: 99%

“…Stereotactic radiosurgery has gained popularity in recent years. 1,2,4,5,[7][8][9][10][11][12]21 Its effect on the obliteration of AVMs is gradual, with patients remaining at risk for hemorrhage during this latency period. Complete obliteration, after a single session, has been reported to vary between 60% and 80% over 5 years.…”

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confidence: 99%

Stereotactic radiosurgery of intracranial arteriovenous malformations and the use of the K index in determining treatment dose

Missios

Bekelis

Alshyal

et al. 2014

FOC

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Object The appropriate dose during stereotactic radiosurgery (SRS) of cerebral arteriovenous malformations (AVMs) remains a matter of debate. In the present study, the authors retrospectively evaluated the association of using a prescribed dose calculated utilizing the K index with the obliteration rate of cerebral AVMs after SRS. Methods The authors performed a retrospective analysis of the Cleveland Clinic SRS database. All patients undergoing Gamma Knife radiosurgery for cerebral AVMs from 1997 to 2010 were selected. Regression techniques and Kaplan-Meier analyses were used to investigate the effect of divergence from the optimal K index dose on the rate of AVM obliteration. Results In the study period 152 patients (mean age 43.6 years; 53.9% of treatments were performed in females) underwent 165 Gamma Knife radiosurgery treatments for AVMs. In a univariate analysis Spetzler-Martin grade (OR 0.63 [95% CI 0.42–0.93]), higher AVM score (OR 0.43 [95% CI 0.27–0.70]), larger AVM volume (OR 0.88 [95% CI 0.82–0.94]), and higher maximum diameter (OR 0.56 [95% CI 0.41–0.77]) were associated with a lower rate of AVM obliteration. Higher margin dose (OR 1.16 [95% CI 1.08–1.24]) and higher maximum dose (OR 1.08 [95% CI 1.04–1.13]) were associated with a higher obliteration rate. To further examine the effect of prescribed dose divergence from the calculated K index dose, cases were classified to groups depending on the AVM volume and dose variance from the ideal K index dose. Contingency tables and Kaplan-Meier curves were then created, and no significant differences in rates of obliteration were noted among the different groups. Conclusions Gamma Knife radiosurgery for cerebral AVMs remains an effective and safe treatment modality. Smaller AVMs may receive doses less than the calculated K index dose without an apparent effect on obliteration rates.

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

Cited by 97 publications

References 53 publications

The long-term outcomes of radiosurgery for arteriovenous malformations in pediatric and adolescent populations

The long-term outcomes of radiosurgery for arteriovenous malformations in pediatric and adolescent populations

Radiosurgery for ruptured intracranial arteriovenous malformations

Stereotactic radiosurgery of intracranial arteriovenous malformations and the use of the K index in determining treatment dose

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