Ching-Jen Chen1, Cheng-Chia Lee2,3, Hideyuki Kano4, Kathryn N Kearns1, Dale Ding5, Shih-Wei Tzeng2, Ahmet Fatih Atik6, Krishna Joshi6, Paul P Huang7, Douglas Kondziolka7, Natasha Ironside1, David Mathieu8, Christian Iorio-Morin8, Inga S Grills9, Thomas J Quinn9, Zaid A Siddiqui9, Kim Marvin9, Caleb Feliciano10, Robert M Starke11, Andrew Faramand4, Gene Barnett6, L Dade Lunsford4, Jason P Sheehan1. 1. Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia. 2. Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan. 3. School of Medicine, National Yang-Ming University, Taipei, Taiwan. 4. Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. 5. Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky. 6. Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio. 7. Department of Neurosurgery, New York University Langone Medical Center, New York, New York. 8. Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke, Canada. 9. Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan. 10. Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico. 11. Department of Neurosurgery, University of Miami, Miami, Florida.
Abstract
BACKGROUND: Long-term data regarding stereotactic radiosurgery (SRS) as a standalone therapy for unruptured pediatric brain arteriovenous malformations (AVMs) are incompletely defined. OBJECTIVE: To evaluate, in a multicenter, retrospective cohort study, the outcomes after SRS for unruptured, intervention-naïve pediatric AVMs. METHODS: To retrospectively analyze the International Radiosurgery Research Foundation pediatric AVM database from 1987 to 2018. Pediatric patients with unruptured, previously untreated AVMs who underwent SRS were included. The primary endpoint was a composite of hemorrhagic stroke, death, or permanently symptomatic radiation-induced changes. RESULTS: The study cohort comprised 101 patients (mean follow-up 80.8 mo). The primary endpoint occurred in 14%, comprising hemorrhagic stroke, death, and permanent radiation-induced changes in 6%, 3%, and 8%, respectively. Estimated probabilities of the primary endpoint were 5.2%, 10.8%, and 23.0% at 2, 5, and 10 yr, respectively. Estimated probabilities of AVM obliteration at 5 and 10 yr were 64% and 82%, respectively. Single SRS treatment (P = .007) and higher margin dose (P = .005) were predictors of obliteration. Subgroup analysis of Spetzler-Martin grade I-III AVMs estimated primary endpoint probabilities of 3.7%, 8.4%, and 18.7% at 2, 5, and 10 yr, respectively. CONCLUSION: Treatment of unruptured, intervention-naïve AVMs in the pediatric population with SRS carries an approximately 2% annual risk of morbidity and mortality, which appears to plateau after 10 yr. The poorly described natural history of pediatric AVMs renders any comparison of SRS vs conservative management imperfect.
BACKGROUND: Long-term data regarding stereotactic radiosurgery (SRS) as a standalone therapy for unruptured pediatric brain arteriovenous malformations (AVMs) are incompletely defined. OBJECTIVE: To evaluate, in a multicenter, retrospective cohort study, the outcomes after SRS for unruptured, intervention-naïve pediatric AVMs. METHODS: To retrospectively analyze the International Radiosurgery Research Foundation pediatric AVM database from 1987 to 2018. Pediatric patients with unruptured, previously untreated AVMs who underwent SRS were included. The primary endpoint was a composite of hemorrhagic stroke, death, or permanently symptomatic radiation-induced changes. RESULTS: The study cohort comprised 101 patients (mean follow-up 80.8 mo). The primary endpoint occurred in 14%, comprising hemorrhagic stroke, death, and permanent radiation-induced changes in 6%, 3%, and 8%, respectively. Estimated probabilities of the primary endpoint were 5.2%, 10.8%, and 23.0% at 2, 5, and 10 yr, respectively. Estimated probabilities of AVM obliteration at 5 and 10 yr were 64% and 82%, respectively. Single SRS treatment (P = .007) and higher margin dose (P = .005) were predictors of obliteration. Subgroup analysis of Spetzler-Martin grade I-III AVMs estimated primary endpoint probabilities of 3.7%, 8.4%, and 18.7% at 2, 5, and 10 yr, respectively. CONCLUSION: Treatment of unruptured, intervention-naïve AVMs in the pediatric population with SRS carries an approximately 2% annual risk of morbidity and mortality, which appears to plateau after 10 yr. The poorly described natural history of pediatric AVMs renders any comparison of SRS vs conservative management imperfect.