Volume-Staged Stereotactic Radiosurgery in Pediatric Patients With Large Brain Arteriovenous Malformations: An International, Multicenter Study

BACKGROUND AND OBJECTIVES: Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosurgery (SRS) is often unsuitable due to constraints on dose-volume toxicity. Volume-staged SRS (VS-SRS) enables sequential dosing of large nidus volumes, potentially enhancing safety while maintaining efficacy. Evidence in children remains limited. We aimed to evaluate outcomes of VS-SRS for large AVMs in pediatric patients. METHODS: A multicenter retrospective cohort was assembled from 21 centers, including patients aged younger than 21 years treated with VS-SRS for AVMs >10 cm3. Clinical and radiological end points included obliteration, hemorrhage, and permanent symptomatic radiation-induced changes (RIC). RESULTS: A total of 103 patients were included (median age 14 years; IQR, 12-17). The median nidus volume at first stage was 18.2 cm3 (IQR, 12.3-25.6). Median prescription dose per stage was 17 Gy (IQR, 16-18). The median clinical follow-up from the first stage was 57.5 months (IQR, 25-138). Obliteration occurred in 42 of 103 patients (40.8%), with actuarial rates of 6.9% (95% CI: 2.8-14) at 3 years and 29% (95% CI: 20-39) at 5 years. Hemorrhage occurred in 17 of 103 patients (16.5%) during follow-up, and permanent RIC was observed in 9 of 103 patients (8.7%). CONCLUSION: VS-SRS is a reasonably safe, selected option for pediatric large-volume AVMs when microsurgical or endovascular cure is not feasible or prudent. Delivering ≥17 Gy per stage while limiting each treatment volume to <15 cm3 supports durable nidus control with acceptable toxicity. VS-SRS represents a key modality in multidisciplinary management of this historically difficult-to-treat population.

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Journal
Neurosurgery
Published
2026-06-16
DOI
https://doi.org/10.1227/neu.0000000000004136
Primary Topic
Vascular Malformations Diagnosis and Treatment
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article
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article

Volume-Staged Stereotactic Radiosurgery in Pediatric Patients With Large Brain Arteriovenous Malformations: An International, Multicenter Study

Herwin Speckter, C Y Chen, Mark J. Amsbaugh, Rituraj Upadhyay et al.
Neurosurgery
Vascular Malformations Diagnosis and Treatment
article

Volume-Staged Stereotactic Radiosurgery in Pediatric Patients With Large Brain Arteriovenous Malformations: An International, Multicenter Study

Herwin Speckter, C Y Chen, Mark J. Amsbaugh, Rituraj Upadhyay, Amr M. N. El-Shehaby, Manjul Tripathi, S A Peker, Penny K. Sneed, CAROLINA BENJAMIN, Zachary Seymour, Jason P. Sheehan, Ahmed M. Nabeel, Stylianos Pikis, Bardia Hajikarimloo, Ronald E. Warnick, Veronica Chiang, Georgios Mantziaris, Andrea Franzini, Yuki Shinya, David R Hallan, Tomáš Chytka, Othman Bin-Alamer, Nuria Martínez Moreno, Roberto Martínez Álvarez, Ying Meng, S.P. Singh, Luigi Alberto Andrea Lanterna, Reem M. Emad, Angel I. Blanco, Joshua D. Palmer, Khaled Abdelkarim, Louis Carrier, Wael A. Reda, Jennifer L. Peterson, Juan Alzate, Chanju Fritch, Jason W. Chan, Inga Grills, Darrah Sheehan, Timoteo Almeida, Kimball Sheehan, Erwin Lazo, Sameh R. Tawadros, Bao Y. Sciscent, Robert Ferguson, Robert M. Starke, David Mathieu, Piero Picozzi, Greg N. Bowden, Salem M. Tos, Roman Liscak, Yavuz Samanci, Huai-che Yang, Ajay Niranjan, Andrea Becerril-Gaitan, Ahmed Abdelsalam, Cheng-chia Lee, Francis J. Jareczek, Michael W. McDermott, L. Dade Lunsford, Yoshua Esquenazi, Douglas Kondziolka
article en

Abstract

BACKGROUND AND OBJECTIVES: Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosurgery (SRS) is often unsuitable due to constraints on dose-volume toxicity. Volume-staged SRS (VS-SRS) enables sequential dosing of large nidus volumes, potentially enhancing safety while maintaining efficacy. Evidence in children remains limited. We aimed to evaluate outcomes of VS-SRS for large AVMs in pediatric patients. METHODS: A multicenter retrospective cohort was assembled from 21 centers, including patients aged younger than 21 years treated with VS-SRS for AVMs >10 cm3. Clinical and radiological end points included obliteration, hemorrhage, and permanent symptomatic radiation-induced changes (RIC). RESULTS: A total of 103 patients were included (median age 14 years; IQR, 12-17). The median nidus volume at first stage was 18.2 cm3 (IQR, 12.3-25.6). Median prescription dose per stage was 17 Gy (IQR, 16-18). The median clinical follow-up from the first stage was 57.5 months (IQR, 25-138). Obliteration occurred in 42 of 103 patients (40.8%), with actuarial rates of 6.9% (95% CI: 2.8-14) at 3 years and 29% (95% CI: 20-39) at 5 years. Hemorrhage occurred in 17 of 103 patients (16.5%) during follow-up, and permanent RIC was observed in 9 of 103 patients (8.7%). CONCLUSION: VS-SRS is a reasonably safe, selected option for pediatric large-volume AVMs when microsurgical or endovascular cure is not feasible or prudent. Delivering ≥17 Gy per stage while limiting each treatment volume to <15 cm3 supports durable nidus control with acceptable toxicity. VS-SRS represents a key modality in multidisciplinary management of this historically difficult-to-treat population.

Neurosurgery
Ain Shams University (EG), Université de Sherbrooke (CA), Koç University (TR), Cairo University (EG), National Yang Ming Chiao Tung University (TW), University of Alberta (CA), University of Pittsburgh (US), Oakland University (US), University of California, San Francisco (US), Florida International University (US), Benha University (EG), The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (US), Jacksonville College (US), Taipei Veterans General Hospital (TW), Moffitt Cancer Center (US), Instituto Tecnológico de Santo Domingo (DO), Yale University (US), NYU Langone Health (US), Ain Shams University Hospital (EG), Baptist Health South Florida (US), University Hospital in Motol (CZ), University of Miami Health System (US), Ospedale Papa Giovanni XXIII (IT), Nasser Institute hospital (EG), Mayo Clinic in Florida (US), Hospital Ruber Internacional (ES), Neurological Surgery (US), The University of Texas Health Science Center (US), IRCCS Humanitas Research Hospital (IT), Post Graduate Institute of Medical Education and Research (IN), University of Virginia (US), Jewish Hospital (US), Penn State Milton S. Hershey Medical Center (US), The University of Texas Health Science Center at Houston (US)
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Vascular Malformations Diagnosis and Treatment
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