• El-Shehaby Amr M N AMN Gamma Knife Center Cairo, Cairo, Egypt-Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Electronic address: amr, Wael A Reda, Khaled M Abdel Karim, Reem M Emad Eldin, Ahmed M Nabeel, and Sameh R Tawadros.
• Gamma Knife Center Cairo, Cairo, Egypt-Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Electronic address: amrelshehaby@yahoo.com.
• World Neurosurg. 2019 Dec 1; 132: e604-e612.

ObjectiveLarge brain arteriovenous malformations (AVMs) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged Gamma Knife radiosurgery (VSGR) has been developed for the treatment of large AVMs to increase the efficacy and improve safety of treatment of these lesions. The aim of this study was to assess the efficacy and safety of VSGR technique for the treatment of large brain AVMs.MethodsThe study included patients treated by VSGR between May 2009 and July 2015. All patients had large AVMs (>10 mL). There were 29 patients.ResultsTwenty-four patients completed radiographic follow-up, with 15 obliteration cases (62.5%). A total of 56 sessions were performed. The mean AVM volume was 16 mL (range, 10.1-29.3 mL). The mean prescription dose was 18 Gy (range, 14-22 Gy). The mean follow-up duration was 43 months (range, 21-73 months). One patient died during follow-up of an unrelated cause. Two patients had hemorrhage during follow-up. Symptomatic edema developed in 5 patients (17%). The factors affecting obliteration were smaller total volume, higher dose/stage, nondeep location, compact AVM, AVM score <3, >18 Gy dose, and <15 mL total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (P = 0.012). T2 image changes were affected by Spetzler-Martin grade ≥3 (P = 0.013) and AVM score ≥3 (P = 0.014).ConclusionsVSGR provides an effective and safe treatment option for large brain AVMs. Smaller AVM volume is associated with higher obliteration rate.Copyright © 2019 Elsevier Inc. All rights reserved.

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