Repeat stereotactic radiosurgery for persistent cerebral arteriovenous malformations in pediatric patients.
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Garcia Gracie, Mantziaris Georgios, Pikis Stylianos, Dumot Chloe, Lunsford L Dade, Niranjan Ajay, Wei Zhishuo, Srinivasan Priyanka, Tang Lilly W, Liscak Roman, May Jaromir, Lee Cheng-Chia, Yang Huai-Che, Peker Selcuk, Samanci Yavuz, Nabeel Ahmed M, Reda Wael A, Tawadros Sameh R, Abdel Karim Khaled, El-Shehaby Amr M N, Emad Eldin Reem, Elazzazi Ahmed Hesham, Martínez Moreno Nuria, Martínez Álvarez Roberto, Padmanaban Varun, Jareczek Francis J, McInerney James, Cockroft Kevin M, Alzate Juan Diego, Kondziolka Douglas, Tripathi Manjul, Sheehan Jason P
Аннотация
METHODS: Under the auspices of the International Radiosurgery Research Foundation, this retrospective multicenter study analyzed pediatric patients who underwent repeat, single-session SRS between 1987 and 2022. The primary outcome variable was a favorable outcome, defined as nidus obliteration without hemorrhage or neurological deterioration. Secondary outcomes included rates and probabilities of hemorrhage, radiation-induced changes (RICs), and cyst or tumor formation.
RESULTS: The cohort included 83 pediatric patients. The median patient age was 11 years at initial SRS and 15 years at repeat SRS. Fifty-seven children (68.7%) were managed exclusively using SRS, and 42 (50.6%) experienced hemorrhage prior to SRS. Median AVM diameter and volume were substantially different between the first (25 mm and 4.5 cm3, respectively) and second (16.5 mm and 1.6 cm3, respectively) SRS, while prescription dose and isodose line remained similar. At the 5-year follow-up evaluation from the second SRS, nidus obliteration was achieved in 42 patients (50.6%), with favorable outcome in 37 (44.6%). The median time to nidus obliteration and hemorrhage was 35.5 and 38.5 months, respectively. The yearly cumulative probability of favorable outcome increased from 2.5% (95% CI 0.5%-7.8%) at 1 year to 44% (95% CI 32%-55%) at 5 years. The probability of achieving obliteration followed a similar pattern and reached 51% (95% CI 38%-62%) at 5 years. The 5-year risk of hemorrhage during the latency period after the second SRS reached 8% (95% CI 3.2%-16%). Radiographically, 25 children (30.1%) had RICs, but only 5 (6%) were symptomatic. Delayed cyst formation occurred in 7.2% of patients, with a median onset of 47 months. No radiation-induced neoplasia was observed.
CONCLUSIONS: The study results showed nidus obliteration in most pediatric patients who underwent repeat SRS for persistent AVMs. The risks of symptomatic RICs and latency period hemorrhage were quite low. These findings suggest that repeat radiosurgery should be considered when treating pediatric patients with residual AVM after prior SRS. Further study is needed to define the role of repeat SRS more fully in this population.