Radiosurgery for childhood intracranial arteriovenous malformations

OBJECTIVE: The optimal management of intracranial arteriovenous malformatio ns (AVMs) in children remains controversial. Children with intracranial AVM s present a special challenge in therapeutic decision-making because of the early recognition of their future life-long risks of hemorrhage if they ar e treated conservatively. The goals of radiosurgery are to achieve complete AVM obliteration and to preserve neurological function. We present long-te rm outcomes for a series of children treated using radiosurgery. METHODS: The findings for 53 consecutive children who underwent at least 36 months of imaging follow-up monitoring after radiosurgery were reviewed. T he median age at the time of treatment was 12 years (range, 2-17 yr). Thirt y-one children (58%) presented after their first intracranial hemorrhaging episodes, two (4%) after their second hemorrhaging episodes, and one (2%) a fter five hemorrhaging episodes. Nineteen children (36%) presented with unr uptured AVMs, and a total of 25 children (47%) exhibited neurological defic its. AVMs were graded as Spetzler-Martin Grade I (2%), Grade II (23%), Grad e III (36%), Grade IV (9%), or Grade VI (30%). The median AVM volume was 1. 7 mi (range, 0.11-10.2 mi). The median marginal dose was 20 Gy (range, 15-2 5 Gy). RESULTS: Results were stratified according to AVM volumes (Group 1, less th an or equal to 3 mi; Group 2, >3 mi to less than or equal to 10 mi; Group 3 , >10 ml). Twenty-eight patients (80%) in Group 1 and 11 (64.7%) in Group 2 achieved complete obliteration. The only patient in Group 3 did not achiev e obliteration. Complications included brainstem edema (n = 1) and transien t pulmonary edema (n = 1). Four patients experienced hemorrhaging episodes, 30, 40, 84, and 96 months after radiosurgery. Multivariate logistic regres sion analysis demonstrated that only volume was significantly correlated wi th obliteration rates (P = 0.0109). CONCLUSION: Radiosurgery is safe and efficacious for selected children with AVMs. The obliteration rates and the attendant low morbidity rates suggest a primary role for stereotactic radiosurgery for pediatric AVMs.