title: Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients.
abstract: BACKGROUND
  Unruptured cerebral arteriovenous malformations (AVMs) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs (ARUBA). Therefore, the efficacy of radiosurgery for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following radiosurgery for unruptured AVMs in pediatric patients.
  
  
  METHODS
  We evaluated a prospective database, from 1989 to 2013, of AVM patients treated with radiosurgery at our institution. Patients with age less than 18 years at the time of radiosurgery, unruptured nidi, and at least 2 years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration.
  
  
  RESULTS
  In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure in 53 %. The median nidus volume and radiosurgical margin dose were 3.2 cm(3) and 21.5 Gy, respectively. The median radiologic follow-up was 45 months. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29 %, 54 %, and 72 %, respectively. In the multivariate Cox proportional hazards regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. Obliteration rates were significantly higher with a margin dose of at least 22 Gy (P = 0.003) and for nidi with 2 or fewer draining veins (P = 0.001). The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55 %, 16 %, and 2 %, respectively. The annual post-radiosurgery hemorrhage rate was 1.3 %, and the incidence of post-radiosurgery cyst formation was 2 %.
  
  
  CONCLUSIONS
  Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach.
authors.affiliation: Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, 22908, USA.
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.forename: Zhiyuan
authors.initials: Z
authors.lastname: Xu
authors.forename: Chun-Po
authors.initials: CP
authors.lastname: Yen
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
mesh_terms: D000293:Adolescent; D001164:Arteriovenous Fistula / Q000473:pathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000473:pathology / Q000601:surgery*; D008297:Male; D011446:Prospective Studies; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D018570:Risk Assessment; D016896:Treatment Outcome