Optimal timing for Gamma Knife surgery after hemorrhage from brain arteriovenous malformations

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Optimal timing of Gamma Knife surgery (GKS) after hemorrhage from brain arteriovenous malformations (AVMs) is unclear and of concern to neurosurgeons because GKS is usually performed after absorption of the hematoma. The authors investigated whether waiting for hematoma absorption is beneficial and aimed to clarify the optimal treatment timing.


The authors retrospectively studied 211 patients with AVMs who presented with hemorrhage and underwent GKS as the initial treatment. Patients were categorized into 3 groups according to the interval between the time of first hemorrhage and GKS, as follows: Group 1, 0–3 months (70 patients); Group 2, 3–6 months (62 patients); and Group 3, > 6 months (79 patients). The obliteration rates, number of hemorrhages before and after GKS, and complication rates were compared between these 3 groups. The authors also analyzed a subgroup of 127 patients who presented with intracerebral hemorrhage (ICH) to identify the influence of ICH on outcome.


After a median follow-up of 6.3 years, the rates of obliteration, hemorrhage after treatment, and complication were not significantly different between the 3 groups even though the patients with a longer interval before GKS (Group 3) had more AVMs in eloquent areas and neurological deficits. However, the numbers of patients with preoperative hemorrhage in the interval before GKS was significantly higher in Group 3 (1, 3, and 20 patients in Group 1, 2, and 3, respectively). These results were similar in the analyses of 127 patients presenting with ICH.


No benefit was detected in waiting for hematoma absorption until GKS after hemorrhage from AVM. Because of higher hemorrhagic risk until GKS > 6 months after hemorrhage, the authors recommend GKS within 6 months after hemorrhage.

Abbreviations used in this paper: AVM = arteriovenous malformation; GKS = Gamma Knife surgery; ICH = intracerebral hemorrhage.

Article Information

Address correspondence to: Keisuke Maruyama, M.D., Ph.D., Department of Neurosurgery, The University of Tokyo Hospital 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. email: kskmaru-tky@umin.ac.jp.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Graph showing actuarial obliteration rate according to the timing of GKS after AVM hemorrhage.

  • View in gallery

    Graph showing actuarial obliteration rates for patients presenting with ICH.


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