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Daniel Tonetti, Hideyuki Kano, Gregory Bowden, John C. Flickinger and L. Dade Lunsford

-old woman with a 1-year history of headaches was found to have a right medial anterior temporal Spetzler-Martin Grade III (S2V1E0) AVM ( Fig. 2 ), which had several arterial feeders and draining veins, deep venous drainage, and a varix but no prenidal or intranidal aneurysms. SRS was performed for this 10-cm 3 AVM; 17 Gy was delivered at the margin in a single SRS session. Fourteen months later, the patient sustained an AVM hemorrhage and was subsequently found to be in her 6th week of pregnancy. She underwent craniotomy for clot evacuation and partial AVM removal. Four

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Douglas Kondziolka, Seyed H. Mousavi, Hideyuki Kano, John C. Flickinger and L. Dade Lunsford

Leksell and Norén as a potential alternative surgical procedure. 28 Since then, more than 50,000 patients worldwide have undergone SRS using the Leksell Gamma Knife (AB Elekta). This incision-free procedure, as well as other linear accelerator–based technologies, has greatly expanded the management options for patients with vestibular schwannomas. Patients no longer need to choose simply between craniotomy or observation, a strategy that only makes sense if such tumors cease to grow after initial recognition and cease to cause additional neurological dysfunction

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Hideyuki Kano, Douglas Kondziolka, Oscar Zorro, Javier Lobato-Polo, John C. Flickinger and L. Dade Lunsford

imaging at intervals of 1–3 months after SRS. The decision for craniotomy and resection after SRS was based on evidence of clinical deterioration and associated imaging progression. Neuroimaging indications included an enlarging lesion, hemorrhage, and symptomatic mass effect unresponsive to medical management that included corticosteroids. Patients were reevaluated clinically and by imaging at intervals of 1–3 months after resection. The follow-up MR images were compared with the preoperative images and tumor dimensions were measured in axial, sagittal, and coronal

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Douglas Kondziolka, Oscar Zorro, Javier Lobato-Polo, Hideyuki Kano, Thomas J. Flannery, John C. Flickinger and L. Dade Lunsford

W hen medical management fails to control the pain of trigeminal neuralgia, patients require surgical intervention. Effective surgical procedures include craniotomy and microvascular decompression or percutaneous ablative procedures. 19 All surgical procedures have variable but definite rates of risk and pain recurrence. Gamma Knife surgery is a minimally invasive surgical approach for managing trigeminal neuralgia. In 1951, Lars Leksell advocated radiosurgery using a prototype guiding device linked to a dental x-ray machine. 14 , 15 During the next 50

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Neal Luther, Douglas Kondziolka, Hideyuki Kano, Seyed H. Mousavi, John C. Flickinger and L. Dade Lunsford

T he role of SRS in the management of metastatic brain tumors continues to expand. The efficacy of SRS for brain metastases is well documented, with tumor control varying from 70% to 90%. 2 , 10 , 12 , 15 , 17 , 19 , 21 , 24 , 29 Additionally, the need for hospitalization for craniotomy or frequent visits for fractionated external-beam radiation therapy are avoided, as are neurocognitive sequelae associated with whole-brain radiation therapy. 1 , 4 , 12 Patients with brain metastases tolerate the procedure well, with generally < 10% developing any signs

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Greg Bowden, Hideyuki Kano, Ellen Caparosa, Seong-Hyun Park, Ajay Niranjan, John Flickinger and L. Dade Lunsford

and presentation with intracranial metastases. Two hundred eighty-one patients (39%) had a synchronous diagnosis. Four hundred forty-nine patients (62%) presented with multiple metastases (range 2–23), and 271 patients (38%) presented with a solitary metastasis. Active systemic disease was present in 549 patients (76%) and extracranial metastases were identified in 271 patients (31%) at the time of SRS. Prior to SRS, 85 patients (12%) had undergone a craniotomy for gross-total resection of at least 1 tumor and 373 patients (52%) had received WBRT. In response to

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Greg Bowden, Hideyuki Kano, Huai-che Yang, Ajay Niranjan, John Flickinger and L. Dade Lunsford

identified in 23 patients (12%) and a venous outflow varix in 28 patients (15%). Endovascular embolization was conducted one or more times in 34 patients (18%) prior to GKS ( Table 1 ). Adverse effects from embolization occurred in 8 patients. Surgical intervention was required in 25 patients (13%) prior to GKS. Nine patients underwent a craniotomy for clot evacuation, 7 patients had a ventriculostomy, 5 patients had partial AVM resection, and 4 patients underwent clipping of a coexisting aneurysm. Surgery prior to GKS was undertaken more often in female patients (n = 15

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Greg Bowden, Hideyuki Kano, Daniel Tonetti, Ajay Niranjan, John Flickinger, Yoshio Arai and L. Dade Lunsford

performed before referral for SRS for 19 patients (22%). Also before SRS, 15 patients (17%) underwent a craniotomy; 6 patients underwent partial AVM resection, 5 patients underwent hematoma evacuation, and 4 underwent hematoma evacuation and AVM resection. Before patients underwent SRS, the Spetzler-Martin grade was determined by 2 experienced neurosurgeons. 37 A Grade II AVM was diagnosed for 26 patients (30%), Grade III for 43 (49%), Grade IV for 16 (18%), and Grade VI for 2. The Pollock-Flickinger score was calculated as Grade I (< 1) for 22 patients (25%), Grade II

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Hideyuki Kano, John C. Flickinger, Huai-che Yang, Thomas J. Flannery, Daniel Tonetti, Ajay Niranjan and L. Dade Lunsford

permanent neurological deficits. Only 1 patient with an SM Grade IIIc AVM sustained a hemorrhage after SRS and permanent symptomatic AREs thereafter. Nine patients (1.9%) developed delayed cyst formation at a median of 28 months (range 6–210 months) after SRS. One patient required a craniotomy and cyst fenestration that resulted in clinical resolution of symptoms. Additional Management Fifty-nine patients with still patent AVMs underwent a second SRS procedure at a median of 42 months (range 18–263 months) after the first procedure. The prescription dose

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Donald N. Liew, Hideyuki Kano, Douglas Kondziolka, David Mathieu, Ajay Niranjan, John C. Flickinger, John M. Kirkwood, Ahmad Tarhini, Stergios Moschos and L. Dade Lunsford

hundred eighteen patients (35%) underwent prior WBRT, usually 30 Gy in 10–14 fractions (range 21–60 Gy). Radiosurgery was performed as a planned boost to WBRT (within 4 weeks) in 30% of patients. Sixty-three patients (19%) underwent surgery prior to radiosurgery (craniotomy resection of tumor in 50 patients, stereotactic biopsy in 10, and needle aspiration of tumor cyst in 3). At the time of radiosurgery, 182 patients (55%) were asymptomatic, 27 patients (8%) had headache only, 17 patients (5%) had seizures, 94 patients (28%) had focal deficits, and 13 patients (4%) had