Robotic radiosurgery for the treatment of pediatric arteriovenous malformations
Bibliographic record
Abstract
OBJECTIVE: Pediatric intracranial arteriovenous malformations (AVMs) have a greater cumulative lifetime risk of rupture than those in adults. Although obliteration after radiation occurs in a dose-dependent manner, increasing radiation doses must be balanced against the risk of adverse radiation effects (AREs). The authors aimed to assess the efficacy of robotic radiosurgery for pediatric AVMs. METHODS: The authors performed a retrospective review of pediatric patients with AVMs at a single institution who underwent robotic radiosurgery between 2005 and 2021 with one of 3 radiosurgery dosing schedules: 1) single-stage unfractionated (SSU), 2) single-stage fractionated (SSF), and 3) volumetrically multistaged (VMS) treatment. Cox proportional hazards regression was performed to identify predictors of AREs and obliteration. RESULTS: Ninety-five patients with 100 intracranial AVMs were identified. Median (range) follow-up time was 4.5 (1.8-15.2) years. Forty-four (46.3%) presented with ruptured AVMs. The mean ± SD AVM volume was 10.0 ± 11.88 cm3. A plurality of AVMs were Spetzler-Martin grade III (36.2%). The overall rate of total obliteration was 52.6% (78.8% of SSU-treated, 24.2% of SSF-treated, 10% of VMS-treated patients) with a median (range) obliteration time of 3.25 (2.8-4.1) years. Partial obliteration was achieved in 23.2% of patients. In the univariate analysis, the higher obliteration rate was associated with small volume (HR 0.876, 95% CI 0.812-0.945) (p = 0.001), no prior embolization (HR 0.472, 95% CI 0.254-0.876) (p = 0.017), lower Spetzler-Martin grade (HR 0.437, 95% CI 0.320-0.597) (p ≤ 0.001), and higher single-fraction equivalent dose (HR 1.160, 95% CI 1.020-1.198) (p = 0.015). Pretreatment hemorrhage was found in 51 patients (59.6% of SSU-treated, 45.5% of SSF-treated, and 50% of VMS-treated patients). Thirteen patients experienced posttreatment hemorrhage (3.8% of SSU-treated, 12% of SSF-treated, and 60% of VMS-treated patients). AREs were found afterward in 31.6% of patients. The correlations of male sex (HR 0.447, 95% CI 0.199-1.004) (p = 0.051) and volume of brain tissue that received a single-fraction equivalent dose of 12 Gy or greater (HR 1.020, 95% CI 1.000-1.041) (p = 0.053) with AREs did not reach significance. CONCLUSIONS: SSU treatment was effective for treating smaller AVMs with an obliteration rate of 79%. Although SSF treatment was less effective in achieving total obliteration (24%), this approach significantly reduced the posttreatment hemorrhage rate by nearly 75% (46% of patients had pretreatment hemorrhage vs 12% with posttreatment hemorrhage). Unfortunately, only 10% of AVMs in the VMS cohort were obliterated and posttreatment hemorrhage rates were not reduced.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".