Journal Mobile Options
Table of Contents
Vol. 89, No. 6, 2011
Issue release date: December 2011
Stereotact Funct Neurosurg 2011;89:365–371

Staged Gamma Knife Radiosurgery for Large Cerebral Arteriovenous Malformations

Amponsah K. · Ellis T.L. · Chan M.D. · Bourland J.D. · Glazier S.S. · McMullen K.P. · Shaw E.G. · Tatter S.B.
Departments of aNeurosurgery and bRadiation Oncology, Wake Forest University Baptist Medical Center, Winston-Salem, N.C., cDepartment of Neuroscience, MUSC, Charleston, S.C., USA

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Background: We present our experience over a 10-year period of staged radiosurgery for large arteriovenous malformations (AVMs) including patient outcomes and methods. Methods: From July 2000 to December 2010, 80 patients with AVMs were treated with gamma knife radiosurgery (GKS) at our institution; of these patients, 5 were treated for large AVMs with staged GKS (volumes >20 cm3). The mean interval between treatments was 10 months (range 7–16). The mean dose for the margin used was 18.0 Gy (range 16–20). The mean volume treated was 37.2 cm3 (range 22–50). The mean total follow-up was 76.5 months (range 42–120). Results: Two patients had complete obliteration of the AVM nidus. One patient had 95% obliteration (31 months after radiosurgery), one had 90% obliteration (38 months after radiosurgery), and one had less than 50% obliteration at 53 months with a 16-month interval between staged treatments. Conclusions: Staged radiosurgery is an effective and safe method for the treatment of large AVMs. We report achieving higher marginal doses with staging in planned intervals of 6–9 months between staged treatments. It appears that the longer the wait between treatments, the less likely it is that complete obliteration will be achieved.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. Schneider BF, Eberhard DA, Steiner LE: Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 1997;87:352–357.
  2. de Oliveira E, Tedeschi H, Raso J: Comprehensive management of arteriovenous malformations. Neurol Res 1998;20:673–683.
  3. Hamilton MG, Spetzler RF: The prospective application of a grading system for arteriovenous malformations. Neurosurgery 1994;34:2–7.
  4. Chung WY, Shiau CY, Wu HM, et al: Staged radiosurgery for extra-large cerebral arteriovenous malformations: method, implementation, and results. J Neurosurg 2008;109:65–72.
  5. Firlik AD, Levy EI, Kondziolka D, Yonas H: Staged volume radiosurgery and resection: a new treatment for giant arteriovenous malformation. Neurosurgery 1998;43:1223–1228.
  6. Pan DH, Guo WY, Chung WY, Shiau CY, Chang YC, Wang LW: Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations. J Neurosurg 2000;93(suppl 3):113–119.
  7. Pollock BE, Kline RW, Stafford SL, Foote RL, Schomberg PJ: The rationale and technique of staged-volume arteriovenous malformation radiosugery. Int J Radiat Oncol Biol Phys 2000;48:817–824.
  8. Sirin S, Kondziolka D, Nirajan A, Flickinger JC, Maitz AH, Lunford LD: Prospective staged volume radiosurgery for large arteriovenous malformations: indications and outcomes in otherwise untreatable patients. Neurosurgery 2006;58:17–27.
  9. Ellis TL, Friedman WA, Bova FJ, et al: Analysis of treatment failure after radiosurgery for arteriovenous malformations. J Neurosurg 1998;89:104–110.
  10. Celix JM, Douglas JG, Haynor D, Goodkin R: Thrombosis and hemorrhage in the acute period following gamma knife surgery for arteriovenous malformation. J Neurosurg 2009;111:124–131.
  11. Chang JH, Chang JW, Park YG, Chung SS: Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 2000;93(suppl 3):96–101.
  12. Friedman WA, Blatt DL, Bova FJ, Buatti JM, Mendenhall WM, Kubilis PS: The risk of hemorrhage after radiosugery for arteriovenous malformations. J Neurosurg 1996;84:912–919.
  13. Inoue H, Ohye C: Hemorrhage risks and obliteration rates of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 2002;97(suppl 5):474–476.

    External Resources

  14. Kasliwal MK, Kale SS, Gupta A, et al: Outcome after hemorrhage following gamma knife surgery for cerebral arteriovenous malformations. J Neurosurg 2009;110:1003–1009.
  15. Ondra SL, Troupp H, George ED, Schwab K: The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 1990;73:387–391.
  16. Pollock BE, Kondziolka D, Lunsford LD, et al: Repeat stereotactic radiosurgery of arteriovenous malformations: factors associated with incomplete obliteration. Neurosurgery 1996;38:318–324.
  17. Colombo F, Pozza F, Chierego G, et al: Linear accelerator radiosurgery of cerebral arteriovenous malformations an update clinical study. Neurosurgery 1994;34:14–21.
  18. Engenhart R, Wowra B, Debus J, Kimmig BN, Hover KH, Lorenz W, et al: The role of high dose, single-fraction irradiation in small and large intracranial arteriovenous malformations. Int J Radiat Oncol Biol Phys 1994;30:521–529.
  19. Flickinger JC, Kondziolka D, Maitz AH, Lunsford LD: An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol 2002;63:347–354.
  20. Karlsson B, Lindquist C, Steiner L: Prediction of obliteration after gamma knife surgery for cerebral arteriovenous malformations. Neurosurgery 1997;40:425–431.
  21. Kwon Y, Jeon R, Kim JH, et al: Analysis of the causes of treatment failure in gamma knife radiosurgery for intracranial arteriovenous malformations. J Neurosurg 2000;93(suppl 3):104–106.
  22. Lundsford LD, Kondziolka D, Bissonette RL, et al: Stereotactic radiosurgery of brain vascular malformations. Neurosurg Clin N Am 1992;3:79–98.

    External Resources

  23. Lundsford LD, Kondziolka D, Flickinger JC, Bissonette DJ, Jungreis CA, Maitz AH, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 1991;75:512–524.
  24. Pollock BE, Flickinger JC, Lunsford LD, et al: Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 1998;42:1239–1247.
  25. Yamamoto Y, Coffey RJ, Nichols DA, Shaw EG: Interim report on the radiosurgical treatment of cerebral arteriovenous malformations. J Neurosurg 1995;83:832–883.
  26. Yen CP, Varady P, Sheehan J, Steiner M, Steiner L: Subtotal obliteration of cerebral arteriovenous malformations after gamma knife surgery. J Neurosurg 2007;106:361–369.
  27. Soderman M, Andersson T, Karlsson B, Wallace MC, Edner G: Management of patients with brain arteriovenous malformations. Eur J Radiol 2003;46:195–205.
  28. Gobin YP, Laurent A, Merienne L, Schlienger M, Aymard A, Houdart E, et al: Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 1996;85:19–29.
  29. Back AG, Vollmer D, Zeck O, Shkedy C, Shedden PM: Retrospective analysis of unstaged and staged gamma knife with and without preceding embolization for the treatment of arteriovenous malformations. J Neurosurg 2008;109:57–64.

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50