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Shayan Moosa, Ching-Jen Chen, Dale Ding, Cheng-Chia Lee, Srinivas Chivukula, Robert M. Starke, Chun-Po Yen, Zhiyuan Xu and Jason P. Sheehan

large AVMs involve the delivery of radiation doses in stages with dose- or volume-staged SRS. Dose staging is described in the literature as either hypofractionated stereotactic radiotherapy (HSRT) or repeat SRS. Hypofractionated stereotactic radiotherapy is typically performed by administering several small doses of radiation to the AVM over a period of a few weeks. Repeat radiosurgery uses a higher initial dose (yet still lower than traditional single-session SRS for small to moderate AVMs), and another dose is administered after several months or years if there is

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Thomas J. Buell, Daniel M. S. Raper, I. Jonathan Pomeraniec, Dale Ding, Ching-Jen Chen, Davis G. Taylor and Kenneth C. Liu

support of the former. In this report, we document immediate resolution of TS and SS stenosis in a patient with IIH after ICP reduction using high-volume lumbar puncture (HVLP). We are the first to use catheter venous manometry simultaneously with intravascular ultrasonography (IVUS) to study intracranial venous occlusive disease. Case Report History and Examination A 32-year-old, severely obese woman (body mass index [BMI] 51.6 kg/m 2 ) previously diagnosed with IIH presented to the University of Virginia Health System after failed medical management with acetazolamide

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Adeel Ilyas, Ching-Jen Chen, Dale Ding, Davis G. Taylor, Shayan Moosa, Cheng-Chia Lee, Or Cohen-Inbar and Jason P. Sheehan

T he optimal management of large (volume > 10 cm 3 ) brain arteriovenous malformations (AVMs) is controversial. Options for intervention include resection, embolization, and stereotactic radiosurgery (SRS), alone or in combination. 6 , 16 , 17 , 26 , 64 , 79 As stand-alone treatment modalities for large AVMs, microsurgery is associated with relatively high rates of morbidity and mortality, whereas embolization results in low rates of complete nidal obliteration. 35 , 39 , 41 Single-session SRS (SS-SRS) is effective for many small- to medium-sized AVMs but

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Robert M. Starke, Chun-Po Yen, Dale Ding and Jason P. Sheehan

history of hemorrhage, and 67% had AVMs in eloquent locations. Lesion volume was less than 2 cm 3 in 198 patients (19.6%), between 2 and 4 cm 3 in 486 (48.0%), and greater than 4 cm 3 in 328 (32.4%). Pretreatment patient and AVM characteristics are listed in Table 1 . TABLE 1: Patient characteristics and univariate predictors of favorable outcome Pretreatment Characteristics No. (%) * Favorable Outcome Odds Ratio 95% CI p Value males 517 (51.1) 1.10 0.85–1.42 0.462 mean age ± SD (yrs) 33.9 ± 15.8 0.68 0

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Douglas Kondziolka

Ding and colleagues at the University of Virginia provide an analysis of 444 patients who had stereotactic radiosurgery for an arteriovenous malformation (AVM) without evidence of prior symptomatic hemorrhage. 1 The series included patients with a mean AVM volume of 4.2 cm 3 (about 2 cm in diameter), but only 14% of the AVMs were in deep brain locations. The median radiosurgical dose was 20 Gy, which is typically associated with a high obliteration rate. As has been found in other studies, the authors noted that a higher obliteration rate was associated

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Douglas Kondziolka

identification of the AVM shunt, but the morbidity of SRS is a function of the radiation dose and the total volume targeted. Ding and colleagues provide additional evidence that embolization prior to radiosurgery is associated with reduced obliteration rates. 1 , 2 This may be due to difficulties in AVM nidus identification. Most of the data are from the pre-Onyx era, and more information is needed to see if this observation holds true today. We are now exploring the use of radiosurgery as the initial therapy followed by targeted embolization for any hemorrhagic risk

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Manjul Tripathi

TO THE EDITOR: I read with great interest the article by Ilyas et al. 1 ( Ilyas A, Chen CJ, Ding D, et al: Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review. J Neurosurg 128:154–164, January 2018 ) and the commentary by Ye et al. 4 ( Ye Z, Ai X, You C: Volume-staged vs dose-staged SRS for large brain AVMs. J Neurosurg 129:262–265, July 2018 ). Management of a large-volume symptomatic arteriovenous malformation (AVM) is a daunting task, not only for the treatment team but also

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Dale Ding, Chun-Po Yen, Zhiyuan Xu, Robert M. Starke and Jason P. Sheehan

. Factors analyzed in these analyses included sex, age, preradiosurgery hemorrhage, preradiosurgery embolization, AVM volume, AVM location (superficial vs deep and noneloquent vs eloquent), location of draining veins (superficial vs deep), number of draining veins (single vs multiple), prescription dose, number of isocenters, radiological presence of RIC, SM grade, radiosurgery-based AVM scale (RBAS) score, and Virginia Radiosurgery AVM Scale (Virginia RAS) score. The patient, AVM, and treatment characteristics listed above were initially subjected to univariate

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Dale Ding, Chun-Po Yen, Zhiyuan Xu, Robert M. Starke and Jason P. Sheehan

.6%), III in 163 (36.7%), IV in 30 (6.8%), and V in 3 (0.7%). We also calculated the modified Pittsburgh radiosurgery-based AVM score, which accounts for patient age, deep location, and AVM volume. 36 TABLE 1: Preradiosurgery patient and AVM characteristics in 444 cases Characteristic Value sex  male 222 (50.0%)  female 222 (50.0%) age (yrs)  mean 36.9  median 35.8  range 5–82 preradiosurgery embolization 122 (27.4%) preradiosurgery microsurgical resection 20 (4.5%) location

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Dale Ding, Chun-Po Yen, Robert M. Starke, Zhiyuan Xu and Jason P. Sheehan

with unruptured AVMs, and all patients treated with volume-staged radiosurgery. The remaining 639 patients, classified as Cohort A, had ruptured AVMs and radiological follow-up of any duration. In an attempt to account for the latency of successes and complications typically associated with radiosurgery, another cohort, Cohort B, of patients with a minimum of 2 years of radiological follow-up was defined, and this group of patients had 465 ruptured AVMs and the minimum of 2 years of radiological follow-up. Finally, to optimize the power of statistical analyses used