Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review

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OBJECTIVE

Several recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs.

METHODS

A systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis.

RESULTS

A total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%–50.9%) and 32.3% (95% CI 15.9%–48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281).

CONCLUSIONS

Volume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.

ABBREVIATIONS AVM = arteriovenous malformation; DS-SRS = dose-staged SRS; GK = Gamma Knife; LINAC = linear accelerator; RIC = radiation-induced change; SRS = stereotactic radiosurgery; SS-SRS = single-session SRS; VS-SRS = volume-staged SRS.
Article Information

Contributor Notes

Correspondence Jason Sheehan, Department of Neurological Surgery, University of Virginia Health System, Box 800212, Charlottesville, VA 22908. email: jsheehan@virginia.edu.INCLUDE WHEN CITING Published online January 27, 2017; DOI: 10.3171/2016.9.JNS161571.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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