Multistaged volumetric management of large arteriovenous malformations

Hideyuki Kano, Douglas Kondziolka, John C. Flickinger, Kyung-Jae Park, Phillip V. Parry, Huai che Yang, Sait Sirin, Ajay Niranjan, Josef Novotny, L. Dade Lunsford

Research output: Chapter in Book/Report/Conference proceedingChapter

11 Citations (Scopus)


We sought 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 AVMs unsuitable for surgery. Two decades ago, we prospectively began to stage anatomical components in order to deliver higher single doses to AVMs >10 cm3 in volume. Forty-seven patients with large AVMs underwent volume-staged SRS. The median interval between the two SRS procedures was 4.9 months (range, 3-14 months). The median nidus volume was 11.5 cm3 (range, 4.0-26 cm3) in the first stage of SRS and 9.5 cm3 in the second. The median margin dose was 16 Gy (range, 13-18 Gy) for both SRS stages. The actuarial rates of total obliteration after 2-staged SRS were 7, 20, 28 and 36% at 3, 4, 5 and 10 years, respectively. Sixteen patients needed additional SRS at a median interval of 61 months (range, 33-113 months) after the 2-staged SRS. After repeat procedure(s), the eventual obliteration rate was 66% at 10 years. 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. Symptomatic adverse radiation effects were detected in 13% of patients. Successful prospective volume-staged SRS for large AVMs unsuitable for surgery requires 2 or more procedures to complete the obliteration process. Patients remain at risk for hemorrhage if the AVM persists.

Original languageEnglish
Title of host publicationGamma Knife Radiosurgery for Brain Vascular Malformations
PublisherS. Karger AG
Number of pages8
ISBN (Electronic)9783805596206
ISBN (Print)9783805596190
Publication statusPublished - 2012 Dec 12
Externally publishedYes

ASJC Scopus subject areas

  • Medicine(all)

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    Kano, H., Kondziolka, D., Flickinger, J. C., Park, K-J., Parry, P. V., Yang, H. C., Sirin, S., Niranjan, A., Novotny, J., & Lunsford, L. D. (2012). Multistaged volumetric management of large arteriovenous malformations. In Gamma Knife Radiosurgery for Brain Vascular Malformations (Vol. 27, pp. 73-80). S. Karger AG.