• Stylianos Pikis, Georgios Mantziaris, Chloe Dumot, Ahmed Shaaban, Maria Protopapa, Zhiyuan Xu, Ajay Niranjan, Zhishuo Wei, Priyanka Srinivasan, Lilly W Tang, Roman Liscak, Jaromir May, Martinez MorenoNuriaNRadiosurgery Unit, Hospital Ruber Internacional, Madrid, Spain., Roberto Martinez Álvarez, Selcuk Peker, Yavuz Samanci, Ahmed M Nabeel, Wael A Reda, Sameh R Tawadros, Khaled Abdelkarim, El-ShehabyAmr M NAMNGamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt.Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt., Reem M Emad, Ahmed Hesham Elazzazi, Varun Padmanaban, Francis J Jareczek, James McInerney, Kevin M Cockroft, Dade Lunsford, and Jason P Sheehan.
• Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
• Neurosurgery. 2023 Dec 18.

Background And ObjectivesThere are no studies evaluating the efficacy and safety of more than 2 stereotactic radiosurgery (SRS) procedures for cerebral arteriovenous malformations (AVM). The aim of this study was to provide evidence on the role of third single-session SRS for AVM residual.MethodsThis multicenter, retrospective study included patients managed with a third single-session SRS procedure for an AVM residual. The primary study outcome was defined as AVM nidus obliteration without AVM bleeding or symptomatic radiation-induced changes (RIC). Secondary outcomes evaluated were AVM obliteration, AVM hemorrhage, asymptomatic, and symptomatic RIC.ResultsThirty-eight patients (20/38 [52.6%] females, median age at third SRS 34.5 [IQR 20] years) were included. The median clinical follow-up was 46 (IQR 14.8) months, and 17/38 (44.7%) patients achieved favorable outcome. The 3-year and 5-year cumulative probability rates of favorable outcome were 23% (95% CI = 10%-38%) and 53% (95% CI = 29%-73%), respectively. The cumulative probability of AVM obliteration at 3 and 5 years after the third SRS was 23% (95% CI = 10%-37%) and 54% (95% CI = 29%-74%), respectively. AVM bleeding occurred in 2 patients, and 1 of them underwent subsequent resection. The cumulative probability rate of post-SRS AVM hemorrhage remained constant at 5.3% (95% CI = 1%-16%) during the first 5 years of follow-up. Transient symptomatic RIC managed conservatively occurred in 5/38 patients (13.2%) at a median time of 12.5 (IQR 22.5) months from third SRS. Radiation-induced cyst formation was noted in 1 patient (4.2%) 19 months post-SRS. No mortality, radiation-associated malignancy, or permanent symptomatic RIC was noted during follow-up.ConclusionA third single-session SRS to treat a residual intracranial AVM offers obliteration in most patients. The risk of RIC was low, and these effects were transient. While not often required, a third SRS can be performed in patients with persistent residual AVMs.Copyright © Congress of Neurological Surgeons 2023. All rights reserved.

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