Outcome Evaluation of Volume-Staged Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Georgios Mantziaris¹, Bardia Hajikarimloo¹, Salem M Tos¹, Stylianos Pikis^{1

2}, Jason W Chan³, Penny K Sneed³, Michael W McDermott⁴, Zachary A Seymour^{5

6}, Inga Grills⁵, Ahmed M Nabeel^{7

8}, Wael A Reda^{7

8}, Sameh R Tawadros^{7

9}, Khaled Abdelkarim^{7

9}, Amr M N El-Shehaby^{7

9}, Reem M Emad^{7

10}, Othman Bin-Alamer¹¹, L Dade Lunsford¹¹, Ajay Niranjan¹¹, Selcuk Peker¹², Yavuz Samanci¹², Cheng-Chia Lee^{13

14}, Huai-Che Yang^{13

14}, Darrah Sheehan¹, Kimball Sheehan¹, Roman Liscak¹⁵, Tomas Chytka¹⁵, Juan Alzate¹⁶, Douglas Kondziolka¹⁶, Ying Meng¹⁶, Nuria Martinez Moreno¹⁷, Roberto Martinez Álvarez¹⁷, David R Hallan¹⁸, Chanju Fritch¹⁸, Frank Jareczek¹⁸, Bao Sciscent¹⁸, David Mathieu¹⁹, Louis Carrier¹⁹, Ahmed Abdelsalam²⁰, Robert M Starke²⁰, Carolina Benjamin²⁰, Timoteo Almeida²¹, Shakti Pratap Singh²², Manjul Tripathi²², Herwin Speckter²³, Erwin Lazo²³, Ching-Jen Chen²⁴, Yoshua Esquenazi²⁴, Andrea Becerril-Gaitan²⁴, Mark J Amsbaugh²⁵, Angel I Blanco²⁵, Rituraj Upadhyay²⁶, Joshua D Palmer²⁶, Andrea Franzini²⁷, Piero Picozzi²⁷, Luigi Alberto Andrea Lanterna²⁸, Greg N Bowden²⁹, Jennifer Peterson³⁰, Ronald E Warnick³¹, Veronica L Chiang³², Mariam Ishaque¹, Maria Protopapa², Jason P Sheehan¹

Affiliations

¹ Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
² Radiation Oncology and Stereotactic Radiosurgery Center, Athens, Greece.
³ Department of Radiation Oncology, University of California - San Francisco School of Medicine, San Francisco, California, USA.
⁴ Department of Neurosurgery, University of California - San Francisco School of Medicine, San Francisco, California, USA.
⁵ Department of Radiation Oncology, Beaumont Health, Oakland University William Beaumont School of Medicine, Oakland, California, USA.
⁶ Department of Radiation Oncology, Corewell Health, Detroit, Michigan, USA.
⁷ Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.
⁸ Department of Neurosurgery, Benha University, Qalubya, Egypt.
⁹ Department of Neurosurgery and Clinical Oncology, Ain Shams University, Cairo, Egypt.
¹⁰ Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt.
¹¹ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹² Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey.
¹³ Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan.
¹⁴ School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
¹⁵ Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
¹⁶ Department of Neurosurgery, NYU Langone, New York, New York, USA.
¹⁷ Radiosurgery Unit, Hospital Ruber Internacional, Madrid, Spain.
¹⁸ Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
¹⁹ Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada.
²⁰ Department of Neurological Surgery, University of Miami Health System, Miami, Florida, USA.
²¹ Department of Radiation Oncology, University of Miami Health System, Miami, Florida, USA.
²² Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
²³ Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic.
²⁴ Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA.
²⁵ Department of Radiation Oncology, The University of Texas Health Science Center, Houston, Texas, USA.
²⁶ Department of Radiation Oncology, The James Comprehensive Cancer Center Ohio State University, Columbus, Ohio, USA.
²⁷ Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy.
²⁸ Department of Neurosurgery, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy.
²⁹ Department of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada.
³⁰ Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA.
³¹ Gamma Knife Center, Jewish Hospital Mayfield Clinic, Cincinnati, Ohio, USA.
³² Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.

PMID: 40788018
DOI: 10.1227/neu.0000000000003682

Outcome Evaluation of Volume-Staged Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Georgios Mantziaris et al. Neurosurgery. 2025.

. 2025 Aug 11.

doi: 10.1227/neu.0000000000003682. Online ahead of print.

Authors

Affiliations

¹ Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
² Radiation Oncology and Stereotactic Radiosurgery Center, Athens, Greece.
³ Department of Radiation Oncology, University of California - San Francisco School of Medicine, San Francisco, California, USA.
⁴ Department of Neurosurgery, University of California - San Francisco School of Medicine, San Francisco, California, USA.
⁵ Department of Radiation Oncology, Beaumont Health, Oakland University William Beaumont School of Medicine, Oakland, California, USA.
⁶ Department of Radiation Oncology, Corewell Health, Detroit, Michigan, USA.
⁷ Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.
⁸ Department of Neurosurgery, Benha University, Qalubya, Egypt.
⁹ Department of Neurosurgery and Clinical Oncology, Ain Shams University, Cairo, Egypt.
¹⁰ Department of Radiation Oncology, National Cancer Institute, Cairo University, Cairo, Egypt.
¹¹ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹² Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey.
¹³ Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan.
¹⁴ School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
¹⁵ Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
¹⁶ Department of Neurosurgery, NYU Langone, New York, New York, USA.
¹⁷ Radiosurgery Unit, Hospital Ruber Internacional, Madrid, Spain.
¹⁸ Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
¹⁹ Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada.
²⁰ Department of Neurological Surgery, University of Miami Health System, Miami, Florida, USA.
²¹ Department of Radiation Oncology, University of Miami Health System, Miami, Florida, USA.
²² Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
²³ Dominican Gamma Knife Center and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic.
²⁴ Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA.
²⁵ Department of Radiation Oncology, The University of Texas Health Science Center, Houston, Texas, USA.
²⁶ Department of Radiation Oncology, The James Comprehensive Cancer Center Ohio State University, Columbus, Ohio, USA.
²⁷ Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy.
²⁸ Department of Neurosurgery, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy.
²⁹ Department of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada.
³⁰ Department of Radiation Oncology, Mayo Clinic Florida, Jacksonville, Florida, USA.
³¹ Gamma Knife Center, Jewish Hospital Mayfield Clinic, Cincinnati, Ohio, USA.
³² Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.

PMID: 40788018
DOI: 10.1227/neu.0000000000003682

Abstract

Background and objectives: Single-session stereotactic radiosurgery (SRS) has limited role for large arteriovenous malformations (AVM). Volume-staged SRS (VS-SRS) is used to optimize outcomes, but studies reporting results are limited.

Methods: This multicenter retrospective cohort of 378 patients from 21 centers reports results of VS-SRS for the entire AVM nidus. We report favorable outcome, obliteration, hemorrhage, and permanent symptomatic adverse radiation effect rates.

Results: The median age was 31 years (IQR: 19-44) at the first volume stage, with patients treated in 2-4 stages. The median total nidus volume was 21 cm3 (IQR: 13.9-30.1 cm3), and a median prescription dose of 17 Gy (IQR: 16-18 Gy) was used. The median radiographic and clinical follow-up were 48 and 55 months, respectively. Seventy-seven patients (20.4%) had a favorable outcome, with the 3-year and 5-year rates being 3.9% and 18%, respectively. 127 patients (33.6%) achieved obliteration, with the 3-year and 5-year rates being 6.8% and 26%, respectively. Obliteration rates of AVMs <15 cm3 were 81% and 31%, respectively. The latency period hemorrhage incidence rate was 3.02 cases per 100 patient-years; 52 patients (13.8%) had a bleed. Seventy-two patients (19%) had symptomatic adverse radiation effect; in 38 patients (10.1%), these were permanent. Total nidus volume, prescription dose at first stage, diffuse nidus, and prior hemorrhage were all independent affecting outcome rates.

Conclusion: VS-SRS can be used to treat large AVMs as a standalone treatment. Obliteration rates and favorable outcomes are lower than that with smaller AVMs, and repeat treatment is often required. Optimizing treatment plans, by increasing prescription doses, reducing treatment volume at each stage, and increasing the number of stages, may lead to better outcomes.

Keywords: Arteriovenous malformation; Hemorrhage; Radiosurgery; Stroke.

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References

1. Derdeyn CP, Zipfel GJ, Albuquerque FC, et al. Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48(8):e200-e224.
1. Mohr JP, Overbey JR, Hartmann A, et al. Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial. Lancet Neurol. 2020;19(7):573-581.
1. Stefani MA, Porter PJ, terBrugge KG, Montanera W, Willinsky RA, Wallace MC. Large and deep brain arteriovenous malformations are associated with risk of future hemorrhage. Stroke. 2002;33(5):1220-1224.
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Outcome Evaluation of Volume-Staged Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Affiliations

Outcome Evaluation of Volume-Staged Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

Authors

Affiliations

Abstract

References

LinkOut - more resources

Full Text Sources