====== Proton beam stereotactic radiosurgery ======

Although [[brain arteriovenous malformation]]s (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous [[intracranial hemorrhage]]s. Pediatric bAVMs tend to rupture more frequently and seem to have higher [[recurrence]] rates than bAVMs in adults. Thus, the management of pediatric bAVMs is particularly challenging. In general, the treatment options are conservative treatment, [[microsurgery]], [[endovascular therapy]] (EVT), [[gamma knife]] [[radiosurgery]] (GKRS), proton-beam stereotactic radiosurgery (PSRS), or a combination of the above. In order to identify the best approach to deep-seated pediatric bAVMs, Meling et al., performed a [[systematic review]], according to the [[PRISMA guideline]]s. None of the options seem to offer a clear advantage over the others when used alone. Microsurgery provides the highest obliteration rate, but has higher incidence of neurological complications. EVT may play a role when used as adjuvant therapy, but as a stand-alone therapy, the efficacy is low and the long-term side effects of radiation from the multiple sessions required in deep-seated pediatric bAVMs are still unknown. GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population
((Meling TR, Patet G. What is the best therapeutic approach to a pediatric
patient with a deep-seated brain AVM? Neurosurg Rev. 2019 Apr 13. doi:
10.1007/s10143-019-01101-8. [Epub ahead of print] Review. PubMed PMID: 30980204.
)).