2025 Volume 53 Issue 6 Pages 369-375
Gamma knife radiosurgery (GKRS) is an established and effective treatment option for appropriately selected cerebral arteriovenous malformations (AVMs). Volume-staged GKRS for large AVMs has shown favorable outcomes, with 5-year obliteration rates of 65%, cumulative hemorrhage risk of 13%, mortality rates of 9%, and irreversible radiation-induced complications of 8%. However, outcomes remain suboptimal for large and ruptured medium-sized AVMs.
Standard catheter-based transarterial embolization of the AVM nidus can reduce intranidal shunt flow but often fails to decrease overall nidus volume sufficiently and carries procedural risks. To address these limitations, we propose a multimodal approach: GKRS first—volume-staged for large AVMs and single-session for ruptured medium-sized AVMs—followed by selective arterial embolization during the latency period to reduce residual shunt flow.
This strategy may reduce both embolization-related complications and hemorrhage risk, potentially improving long-term outcomes. Multicenter studies are warranted to validate its safety and efficacy and to establish its role in AVM management.
