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

Hanakita, Shunya; Koga, Tomoyuki; Shin, Masahiro; Igaki, Hiroshi; Saito, Nobuhito

doi:10.3171/2015.1.peds14407

Cited by 52 publications

(19 citation statements)

References 49 publications

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“…Despite advancement of techniques in AVM manage- ment, the risk of hemorrhage persists after treatment and is reported to be 1.4% overall per patient per year in the general patient population. 48 In regard to pediatric patients with AVMs, this rate is 0.3%-4.3% for patients who underwent radiosurgery, 2,3,8,9,17,21,29,37,42,43,54,56,57 and 0%-0.3% for patients after resection. 8,16,50 To the best of our knowledge, this is the first study attempting to compare posttreatment hemorrhagic risk across different treatment modalities in a single cohort of pediatric patients with AVMs.…”

Section: Discussion Hemorrhagic Risk Of Avmsmentioning

confidence: 99%

“…35 In comparison, in a radiosurgical cohort of 116 pediatric patients with AVMs reported recently by Hanakita et al, only 10 patients were reported to develop adverse events, rendering a 91.4% optimal functional outcome, with prior AVM hemorrhage showing marginal association with worse functional outcomes. 17 In a more comprehensive analysis presented by Darsaut et al, where all major modalities were included, the overall proportion of patients achieving good functional outcomes was 74.2%, in which high grade, left side, and poor baseline mRS score were significant predictors in the multivariate analysis. 8 These data are largely consistent with those in our study.…”

Section: Functional Outcomes In Pediatric Patients With Avmsmentioning

confidence: 96%

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Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations

Yang¹,

Anderson-Keightly²,

Westbroek³

et al. 2016

PED

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OBJECTIVE Compared with the general population, the specific natural history of arteriovenous malformations (AVMs) in pediatric patients is less well understood. Furthermore, few pediatric studies have compared posttreatment hemorrhagic risk and functional outcome across different treatment modalities. The objective of this study was to elucidate these points. METHODS The authors retrospectively reviewed all pediatric patients with AVMs evaluated at their institution between 1990 and 2013. The AVM natural history was represented by hemorrhagic risk during the observation period. For treated patients, the observation period was defined as the interval between diagnosis and treatment. Posttreatment hemorrhagic risk and functional outcomes were also assessed. RESULTS A total of 124 pediatric patients with AVMs were evaluated, and 90 patients (72.6%) were retained through follow-up. The average patient age was 13.3 ± 3.8 years, with a mean follow-up period of 9.95 years. The overall AVM obliteration rate was 59.7%. Radiosurgery had an obliteration rate of 49.0%. Thirteen patients were managed conservatively. Four patients under observation hemorrhaged during a total interval of 429.4 patient-years, translating to an annual risk of 0.9%. Posttreatment hemorrhagic risk by treatment modalities were categorized as follows: surgery ± embolization (0.0%), radiosurgery ± embolization (0.8%), embolization alone (2.8%), surgery + radiosurgery ± embolization (3.5%), and observation (0.8%). A significantly higher risk of posttreatment hemorrhage was observed for patients with hemorrhagic presentation (p = 0.043) in multivariate analysis. Seizure presentation, frontal lobe location, nonheadache presentation, and treatment modality were significantly associated with increased risk of poor functional outcomes. CONCLUSIONS In this study of pediatric patients with AVMs, the natural history of hemorrhage was relatively low at 0.9%. Resection remained the optimal management for hemorrhage control and functional outcome perseverance in these pediatric patients with AVMs. AVM obliteration is a valid treatment goal, especially for patients with ruptured presentation, to prevent further hemorrhages later in life.

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Section: Discussion Hemorrhagic Risk Of Avmsmentioning

confidence: 99%

Section: Functional Outcomes In Pediatric Patients With Avmsmentioning

confidence: 96%

Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations

Yang¹,

Anderson-Keightly²,

Westbroek³

et al. 2016

PED

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“…Although the short-term risks of SRS are known to be generally less frequent than those associated to other treatment modalities, the longer, continuous risks of radiation, which may occur even >10 years after treatment, remain unclarified, 20 with its accumulated risks, based on follow-up periods of >20 years, still largely unknown. To definitively determine the clinical benefits of SRS for small unruptured AVM, prospective studies with such long follow-up periods are needed.…”

Section: Strokementioning

confidence: 99%

Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations

Hanakita

Shin

Koga

et al. 2016

Stroke

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Methods-A retrospective review was performed for 292 patients with unruptured arteriovenous malformations referred for SRS. The risks for cerebral hemorrhages were statistically compared before and after SRS. Results-Of the 292 patients in whom arteriovenous malformation was found unruptured at initial diagnosis, 17 sustained hemorrhages in the period between the diagnosis and the initial therapeutic intervention (annual bleeding rate, 2.1%; 95% confidence interval [CI], 1.2%-3.4%). Of the remaining 275 patients, 240 were initially treated with SRS, and 16 sustained a hemorrhage after SRS (annual bleeding rate, 1.1%; 95% CI, 0.6%-1.8%), but only 2 sustained a hemorrhage after angiographic obliteration (annual bleeding rate, 0.3%; 95% CI, 0.04%-1.2%

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“…Initially, only biplanar digital subtraction angiography (DSA) was used; however, owing to modern advances in radiological techniques and the development of planning software, CT angiography (CTA) and MRI have become valuable tools, as they enable axial image-based radiosurgical planning, which improves the quality of target contouring. 4,17,20,21,24 Since radiotherapy planning is solely dependent on radiological images, using high-resolution images is essential, as such images can theoretically reduce radiation waste and avoid suboptimal coverage of the targets, ultimately improving the radiosurgical outcome. 12,22 However, the imaging modality best suited to provide high-resolution images for GKS planning remains unknown.…”

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confidence: 99%

Integration of rotational angiography enables better dose planning in Gamma Knife radiosurgery for brain arteriovenous malformations

Hasegawa¹,

Hanakita²,

Shin³

et al. 2018

Journal of Neurosurgery

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OBJECTIVEIn Gamma Knife radiosurgery (GKS) for arteriovenous malformations (AVMs), CT angiography (CTA), MRI, and digital subtraction angiography (DSA) are generally used to define the nidus. Although the AVM angioarchitecture can be visualized with superior resolution using rotational angiography (RA), the efficacy of integrating RA into the GKS treatment planning process has not been elucidated.METHODSUsing data collected from 25 consecutive patients with AVMs who were treated with GKS at the authors’ institution, two neurosurgeons independently created treatment plans for each patient before and after RA integration. For all patients, MR angiography, contrasted T1 imaging, CTA, DSA, and RA were performed before treatment. The prescription isodose volume before (PIVB) and after (PIVA) RA integration was measured. For reference purposes, a reference target volume (RTV) for each nidus was determined by two other physicians independent of the planning surgeons, and the RTV covered by the PIV (RTVPIV) was established. The undertreated volume ratio (UVR), overtreated volume ratio (OVR), and Paddick’s conformal index (CI), which were calculated as RTVPIV/RTV, RTVPIV/PIV, and (RTVPIV)2/(RTV × PIV), respectively, were measured by each neurosurgeon before and after RA integration, and the surgeons’ values at each point were averaged. Wilcoxon signed-rank tests were used to compare the values obtained before and after RA integration. The percentage change from before to after RA integration was calculated for the average UVR (%ΔUVRave), OVR (%ΔOVRave), and CI (%ΔCIave) in each patient, as ([value after RA integration]/[value before RA integration] − 1) × 100. The relationships between prior histories and these percentage change values were examined using Wilcoxon signed-rank tests.RESULTSThe average values obtained by the two surgeons for the median UVR, OVR, and CI were 0.854, 0.445, and 0.367 before RA integration and 0.882, 0.478, and 0.463 after RA integration, respectively. All variables significantly improved after compared with before RA integration (UVR, p = 0.009; OVR, p < 0.001; CI, p < 0.001). Prior hemorrhage was significantly associated with larger %ΔOVRave (median 20.8% vs 7.2%; p = 0.023) and %ΔCIave (median 33.9% vs 13.8%; p = 0.014), but not %ΔUVRave (median 4.7% vs 4.0%; p = 0.449).CONCLUSIONSIntegrating RA into GKS treatment planning may permit better dose planning owing to clearer visualization of the nidus and, as such, may reduce undertreatment and waste irradiation. Further studies examining whether the observed RA-related improvement in dose planning also improves the radiosurgical outcome are needed.

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

Cited by 52 publications

References 49 publications

Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations

Long-term hemorrhagic risk in pediatric patients with arteriovenous malformations

Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations

Integration of rotational angiography enables better dose planning in Gamma Knife radiosurgery for brain arteriovenous malformations

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