Stereotactic radiosurgery for arteriovenous malformations, Part 6: multistaged volumetric management of large arteriovenous malformations

Clinical article

Restricted access


The object of this study was to define the long-term outcomes and risks of arteriovenous malformation (AVM) management using 2 or more stages of stereotactic radiosurgery (SRS) for symptomatic large-volume lesions unsuitable for surgery.


In 1992, the authors prospectively began to stage the treatment of anatomical components to deliver higher single doses to AVMs with a volume of more than 10 cm3. Forty-seven patients with such AVMs underwent volume-staged SRS. In this series, 18 patients (38%) had a prior hemorrhage and 21 patients (45%) underwent prior embolization. The median interval between the first-stage SRS and the second-stage SRS was 4.9 months (range 2.8–13.8 months). The median target volume was 11.5 cm3 (range 4.0–26 cm3) in the first-stage SRS and 9.5 cm3 in the second-stage SRS. The median margin dose was 16 Gy (range 13–18 Gy) for both stages.


In 17 patients, AVM obliteration was confirmed after 2–4 SRS procedures at a median follow-up of 87 months (range 0.4–209 months). Five patients had near-total obliteration (volume reduction > 75% but residual AVM). The actuarial rates of total obliteration after 2-stage SRS were 7%, 20%, 28%, and 36% at 3, 4, 5, and 10 years, respectively. The 5-year total obliteration rate after the initial staged volumetric SRS with a margin dose of 17 Gy or more was 62% (p = 0.001). Sixteen patients underwent additional SRS at a median interval of 61 months (range 33–113 months) after the initial 2-stage SRS. The overall rates of total obliteration after staged and repeat SRS were 18%, 45%, and 56% at 5, 7, and 10 years, respectively. Ten patients sustained hemorrhage after staged SRS, and 5 of these patients died. Three of 16 patients who underwent repeat SRS sustained hemorrhage after the procedure and died. Based on Kaplan-Meier analysis (excluding the second hemorrhage in the patient who had 2 hemorrhages), the cumulative rates of AVM hemorrhage after SRS were 4.3%, 8.6%, 13.5%, and 36.0% at 1, 2, 5, and 10 years, respectively. This corresponded to annual hemorrhage risks of 4.3%, 2.3%, and 5.6% for Years 0–1, 1–5, and 5–10 after SRS. Multiple hemorrhages before SRS correlated with a significantly higher risk of hemorrhage after SRS. Symptomatic adverse radiation effects were detected in 13% of patients, but no patient died as a result of an adverse radiation effect. Delayed cyst formation did not occur in any patient after SRS.


Prospective volume-staged SRS for large AVMs unsuitable for surgery has potential benefit but often requires more than 2 procedures to complete the obliteration process. To have a reasonable chance of benefit, the minimum margin dose should be 17 Gy or greater, depending on the AVM location. In the future, prospective volume-staged SRS followed by embolization (to reduce flow, obliterate fistulas, and occlude associated aneurysms) may improve obliteration results and further reduce the risk of hemorrhage after SRS.

Abbreviations used in this paper: ARE = adverse radiation effect; AVM = arteriovenous malformation; HR = hazard ratio; SRS = stereotactic radiosurgery.

Article Information

Address correspondence to: L. Dade Lunsford, M.D., Department of Neurological Surgery, University of Pittsburgh, Suite B-400, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email:

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.9.JNS11177.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Studies obtained in a 34-year-old female patient with a large AVM located in the cingulate gyrus who presented with an intraventricular hemorrhage. A and B: Anteroposterior and lateral right internal carotid artery (ICA) angiograms obtained at the time of the volume-staged SRS. C–E: Axial, coronal, and sagittal T1-weighted contrast-enhanced MR images showing an anatomical component of the first volume-staged SRS. F–H: Axial, coronal, and sagittal T1-weighted contrast-enhanced MR images showing an anatomical component of the second volume-staged SRS (8 months after the first). The total target volume was 15.6cm3 and the margin dose was 18 Gy for both stages. I and J: Anteroposterior and lateral right ICA angiograms showing total obliteration 40 months after the second volume-staged SRS.

  • View in gallery

    Flowchart showing outcomes after staged and repeat SRS in 47 patients. N = number of patients.

  • View in gallery

    Upper: Kaplan-Meier curves for total obliteration on MR imaging or angiography after staged radiosurgery for large-volume AVMs with corrected time (solid line) and uncorrected time (broken line). Lower: Kaplan-Meier curves for total obliteration on MR imaging or angiography after staged SRS for large AVMs with a margin dose of 17 Gy or more versus a margin dose less than 17 Gy. A margin dose of 17 Gy or more was significantly associated with a higher total obliteration rate on MR imaging or angiography (p = 0.001).

  • View in gallery

    Kaplan-Meier curve for hemorrhage rate after staged SRS for large AVMs.

  • View in gallery

    Upper: Kaplan-Meier curves for total obliteration on MR imaging or angiography after repeat radiosurgery for residual AVMs. Lower: Kaplan-Meier curves of hemorrhage rate after repeat SRS for residual AVMs.

  • View in gallery

    Kaplan-Meier curve for total obliteration on MR imaging or angiography after staged and repeat radiosurgery.



Chung WYShiau CYWu HMLiu KDGuo WYWang LW: Staged radiosurgery for extra-large cerebral arteriovenous malformations: method, implementation, and results. J Neurosurg 109:Suppl65722008


Colombo FPozza FChierego GCasentini LDe Luca GFrancescon P: Linear accelerator radiosurgery of cerebral arteriovenous malformations: an update. Neurosurgery 34:14211994


Dawson RC IIITarr RWHecht STJungreis CALunsford LDCoffey R: Treatment of arteriovenous malformations of the brain with combined embolization and stereotactic radiosurgery: results after 1 and 2 years. AJNR Am J Neuroradiol 11:8578641990


Firlik ADLevy EIKondziolka DYonas H: Staged volume radiosurgery followed by microsurgical resection: a novel treatment for giant cerebral arteriovenous malformations: technical case report. Neurosurgery 43:122312281998


Flickinger JCKondziolka DLunsford LDKassam APhuong LKLiscak R: Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Int J Radiat Oncol Biol Phys 46:114311482000


Flickinger JCPollock BEKondziolka DLunsford LD: A dose-response analysis of arteriovenous malformation obliteration after radiosurgery. Int J Radiat Oncol Biol Phys 36:8738791996


Friedlander RM: Clinical practice. Arteriovenous malformations of the brain. N Engl J Med 356:270427122007


Gobin YPLaurent AMerienne LSchlienger MAymard AHoudart E: Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85:19281996


Inoue HKOhye C: Hemorrhage risks and obliteration rates of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 97:5 Suppl4744762002


Liscák RVladyka VSimonová GUrgosík DNovotný J JrJanousková L: Arteriovenous malformations after Leksell gamma knife radiosurgery: rate of obliteration and complications. Neurosurgery 60:100510162007


Lunsford LDKondziolka DFlickinger JCBissonette DJJungreis CAMaitz AH: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:5125241991


Ogilvy CSStieg PEAwad IBrown RD JrKondziolka DRosenwasser R: AHA Scientific Statement. Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 103:264426572001


Pan DHGuo WYChung WYShiau CYChang YCWang LW: Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations. J Neurosurg 93:Suppl 31131192000


Paulsen RDSteinberg GKNorbash AMMarcellus MLMarks MP: Embolization of basal ganglia and thalamic arteriovenous malformations. Neurosurgery 44:9919971999


Pollock BEFlickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:79852002


Pollock BEFlickinger JCLunsford LDMaitz AKondziolka D: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42:123912471998


Pollock BEKline RWStafford SLFoote RLSchomberg PJ: The rationale and technique of staged-volume arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys 48:8178242000


Pollock BEKondziolka DFlickinger JCPatel AKBissonette DJLunsford LD: Magnetic resonance imaging: an accurate method to evaluate arteriovenous malformations after stereotactic radiosurgery. J Neurosurg 85:104410491996


Pollock BEMeyer FB: Radiosurgery for arteriovenous malformations. J Neurosurg 101:3903922004


Redekop GJElisevich KVGaspar LEWiese KPDrake CG: Conventional radiation therapy of intracranial arteriovenous malformations: long-term results. J Neurosurg 78:4134221993


Seifert VStolke DMehdorn HMHoffmann B: Clinical and radiological evaluation of long-term results of stereotactic proton beam radiosurgery in patients with cerebral arteriovenous malformations. J Neurosurg 81:6836891994


Sinclair JKelly MESteinberg GK: Surgical management of posterior fossa arteriovenous malformations. Neurosurgery 58:4 Suppl 2ONS-189ONS-2012006


Sirin SKondziolka DNiranjan AFlickinger JCMaitz AHLunsford LD: Prospective staged volume radiosurgery for large arteriovenous malformations: indications and outcomes in otherwise untreatable patients. Neurosurgery 58:17272006


Spetzler RFMartin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:4764831986


Weber WKis BSiekmann RKuehne D: Endovascular treatment of intracranial arteriovenous malformations with onyx: technical aspects. AJNR Am J Neuroradiol 28:3713772007


Wegner REOysul KPollock BESirin SKondziolka DNiranjan A: A modified radiosurgery-based arteriovenous malformation grading scale and its correlation with outcomes. Int J Radiat Oncol Biol Phys 79:114711502011


Yamamoto YCoffey RJNichols DAShaw EG: Interim report on the radiosurgical treatment of cerebral arteriovenous malformations. The influence of size, dose, time, and technical factors on obliteration rate. J Neurosurg 83:8328371995


Yang SYKim DGChung HTPaek SHPark JHHan DH: Radiosurgery for large cerebral arteriovenous malformations. Acta Neurochir (Wien) 151:1131242009




All Time Past Year Past 30 Days
Abstract Views 7 7 5
Full Text Views 128 128 32
PDF Downloads 80 80 29
EPUB Downloads 0 0 0


Google Scholar