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OBJECTIVE Ruptured, large pediatric arteriovenous malformations (AVMs) pose a significant management challenge due to high rerupture risk and the morbidity of conventional treatments. Volume-staged stereotactic radiosurgery (VS-SRS) has emerged as an alternative; however, evidence for its use in this specific population is limited. This study aimed to evaluate the long-term efficacy and safety of VS-SRS for ruptured, large AVMs in a dedicated pediatric cohort. METHODS This international, multicenter, retrospective cohort study from 21 centers analyzed outcomes for 42 pediatric patients (age < 18 years) with previously ruptured, large AVMs treated with VS-SRS. The primary outcome was complete AVM obliteration, and secondary outcomes included post-SRS hemorrhage, radiation-induced changes (RICs), and favorable outcome. Favorable outcome in this study was defined as obliteration without post-SRS hemorrhage or permanent RIC. RESULTS At the initial SRS, the median patient age was 14.5 years, and the median AVM volume was 15.0 cm 3 ; most AVMs were high grade (Spetzler-Martin grades IV and V). With a median follow-up of 41.5 months, complete AVM obliteration was achieved in 21 patients (50.0%). The cumulative obliteration rate was 37% at 5 years and 56% at 10 years. Patients with a nidus volume of ≤ 10 cm 3 had significantly higher cumulative obliteration rates than those with a nidus volume > 10 cm 3 (log-rank test, p = 0.021). Similarly, patients treated with a prescription dose > 17 Gy showed significantly higher cumulative obliteration rates compared to those treated with a dose ≤ 17 Gy (log-rank test, p = 0.012). The cumulative 5-year incidences of hemorrhage and RICs following VS-SRS were 19% and 7%, respectively. In multivariable analysis, only larger total AVM volume was an independent predictor of a lower likelihood of favorable outcome (hazard ratio 0.89, 95% CI 0.80–0.99; p = 0.036). CONCLUSIONS In this multicenter pediatric cohort, VS-SRS for ruptured, large AVMs provides a reasonable chance of long-term obliteration, but generally acceptable risks of post-SRS hemorrhage and RICs exist. VS-SRS should be considered as an option for pediatric patients with large, ruptured AVMs.

e16159 Background: Pivotal trials established atezolizumab-bevacizumab and durvalumab-tremelimumab as first-line therapies for unresectable hepatocellular carcinoma (HCC). Atezolizumab plus bevacizumab demonstrated superior survival outcomes compared to sorafenib for unresectable HCC in the IMbrave150 trial in 2020, while durvalumab plus tremelimumab showed superior survival in the HIMALAYA trial in 2022. However, data on head-to-head comparison of these two combinations as first-line systemic therapy for the patient with decompensated HCC are limited. This study aims to compare survival outcomes between these two treatment regimens in decompensated HCC patients to address a critical gap in the current literature, as decompensated patients have largely been excluded from clinical trials. Methods: This retrospective study utilized electronic health records from 146 U.S. healthcare organizations within the TriNetX Network. Adults aged ≥21 years diagnosed with decompensated HCC receiving atezolizumab/bevacizumab and durvalumab/tremelimumab from 10/21/2022 to 8/20/2024 were included. The comparison group received atezolizumab/bevacizumab, and the control group received durvalumab/tremelimumab. The primary outcome was all-cause mortality. A 1:1 propensity score matching was conducted to balance baseline characteristics (age, gender, race/ethnicity, lab results including liver function tests, platelet counts, INR, gamma glutamyl transferase, alpha-fetoprotein, and underlying liver diseases). Kaplan–Meier survival analysis and Cox regression was used to estimate the mortality risk. Subgroup analysis was stratified by HCC etiology. Results: A total of 302 and 664 patients received durvalumab/tremelimumab, atezolizumab/bevacizumab, respectively. After propensity matching, 253 patients per group were included. Median OS was 283 days with durvalumab/tremelimumab and 391 days with atezolizumab/bevacizumab. The two treatment regimens showed no significant difference in survival (hazard ratio [HR]: 0.875, 95% confidence intervals [CI] 0.696–1.101, p=0.254). Subgroup analyses demonstrated no significant differences in survival between the two groups of patients in MASLD (HR: 0.698, 95% CI: 0.468–1.040), alcohol associated liver disease (HR: 0.821, 95% CI: 0.603–1.118), and chronic viral hepatitis (HR: 0.852, 95% CI: 0.596–1.219). Conclusions: There was no statistically significant difference in survival outcomes between atezolizumab plus bevacizumab and durvalumab plus tremelimumab in patients with decompensated advanced HCC. These results support current real-world practice in which both regimens may be considered viable first-line treatment options in this high-risk population with liver decompensation.

PURPOSE External beam radiation therapy (EBRT) has gained delayed acceptance as a recommended first-line treatment modality for patients with hepatocellular carcinoma (HCC), given limited evidence that it improves overall survival (OS). We analyzed individual patient data (IPD) from an international cohort to assess OS among patients with HCC treated with EBRT. METHODS We performed a systematic review of publications that assessed EBRT, met prespecified technical standards for HCC, and reported OS (search date December 15, 2022). Corresponding authors were invited to submit IPD for the study. We performed Kaplan-Meier survival analyses to determine OS and restricted mean survival time (RMST) stratified by Barcelona Clinic Liver Cancer (BCLC) stage and treatment status (ie, treatment-naïve and experienced). We performed random effects Cox proportional hazards modeling to assess clinical characteristics associated with OS. RESULTS Data were provided on 4,913 patients treated with EBRT with a median follow-up time of 5.0 years. The median OS was 6.8 years (95% CI, 5.7 to 8.7) for BCLC-0 and 4.6 years (95% CI, 4.1 to 5.1) for BCLC-A. Among treatment-naïve patients, the median OS was not reached (95% CI, 8.6 to not reached) for BCLC-0 and was 5.4 years (95% CI, 4.5 to 6.7) for BCLC-A. In multivariable models, more advanced BCLC stage, higher tumor burden, worse performance status, and Child-Pugh class B or C were associated with a higher risk of mortality. Ablative radiation dose and more recent year of treatment were associated with a reduced risk of death. CONCLUSION To our knowledge, this study represents the largest multinational cohort of patients with HCC treated with EBRT. OS outcomes with EBRT for very early- and early-stage HCC appear to be comparable with resection, thermal ablation, and other ablative locoregional therapies. These data support the inclusion of EBRT in the BCLC HCC clinical decision-making process.

Aim To determine whether there is a difference in the time to complete a rapid number naming task during the interictal state compared to prodrome, migraine headache, postdrome phases of migraine and non-migraine headache, and characterize non-headache symptoms experienced during these phases. Methods This prospective longitudinal cohort study evaluated 30 adults with migraine with or without aura who completed diary entries and a timed rapid number naming task at least three times daily for up to four months from October 2020 to July 2022 at a tertiary headache center. Diary entries included self-report of current migraine phase (having a migraine headache, non-migraine headache, prodrome, postdrome, or interictal baseline) and detailed symptoms experienced. The outcome of interest for the timed rapid number naming task was the time to complete the task with zero errors. Results Compared to the interictal baseline, the time with zero errors for the rapid number naming task was significantly slower during the prodrome (median (Q1, Q3) 1.0 s slower (0.4, 2.9), p -value 0.010), migraine headache (median (Q1, Q3) 3.8 s slower (2.6, 7.5), p -value <0.001), and postdrome (median (Q1, Q3) 0.9 s slower (0.2, 2.1), p -value 0.011) phases of migraine, and non-migraine headache attacks (median (Q1, Q3) 1.2 s slower (0.1, 3.1), p -value 0.006). For those with migraine with aura (N = 15), the time with zero errors was significantly slower during all phases compared to interictal phase. For those with migraine without aura (N = 15), the time with zero errors was significantly slower only during the migraine headache, but not other phases compared to the interictal phase. The top 5 most reported non-headache symptoms during any phase of migraine and non-migraine headache attacks included fatigue, neck stiffness, light sensitivity, blurred vision/vision changes, and difficulty concentrating. Conclusions Among the overall participant cohort, the time with zero errors to complete a rapid number naming task was significantly slower during all ictal phases compared to interictal phase. This was also the case in the migraine with aura cohort but in the migraine without aura cohort there was only a significant difference during the migraine headache phase versus interictal phase. There is overlap in non-headache symptoms between the prodrome, migraine headache, postdrome, and non-migraine headache phases, which may make distinguishing between these phases difficult. Combining subjective data, such as symptom diaries, with objective measures, such as rapid number naming tasks, may allow for more refined assessment of migraine phases and distinguishing migraine from non-migraine headache attacks.

Abstract Echocardiography is the most widely used cardiac imaging modality, yet artificial intelligence-enabled interpretation remains limited by the inability of existing models to integrate visual assessment, quantitative measurement, and clinical reasoning within a unified framework. Here we present EchoAtlas, the first autoregressive vision-language model developed for echocardiographic interpretation. Trained on over 12.9 million question-answer pairs derived from approximately 2 million echocardiogram videos, EchoAtlas achieves 0.966 accuracy on multiple-choice questions in our internal test set and establishes a new state-of-the-art on the public MIMIC-EchoQA benchmark (0.699 vs. 0.508 previously). EchoAtlas also provides accurate quantitative measurements, segment-level regional wall motion assessment, longitudinal comparison, and diagnostic reasoning across diverse question formats — capabilities not previously demonstrated in this domain. These results highlight the potential of autoregressive vision-language models as a foundation for interactive echocardiographic interpretation, representing an early step toward scalable, auditable artificial intelligence systems in cardiology practice.