title: Staged volume radiosurgery followed by microsurgical resection: a novel treatment for giant cerebral arteriovenous malformations: technical case report.
abstract: OBJECTIVE
  We describe the successful treatment of symptomatic giant arteriovenous malformations (AVMs) using staged volume radiosurgery followed by microsurgical resection.
  
  
  METHODS
  A 57-year-old man presented with Spetzler-Martin Grade 5 AVMs, with persistent headaches and seizures. He had previously undergone eight attempts at AVM embolization and a craniotomy for attempted AVM resection; he had suffered four episodes of brain hemorrhaging but had made a good neurological recovery.
  
  
  METHODS
  Because of the persistent symptoms of the patient and his history of hemorrhaging, a treatment plan based on staged radiosurgical treatments of different portions of the AVMs (three sessions, spaced 6 mo apart), followed by delayed microsurgical removal of the much-reduced residual AVMs (3 years later), was undertaken. The patient did not suffer any additional hemorrhaging episodes, his AVMs were completely removed, and he has made a good recovery.
  
  
  CONCLUSIONS
  Staged volume radiosurgery followed by microsurgical resection of the residual AVMs represents a novel treatment strategy for the management of Grade 5 AVMs that might be untreatable by any single treatment method used alone.
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
authors.forename: A D
authors.initials: AD
authors.lastname: Firlik
authors.forename: E I
authors.initials: EI
authors.lastname: Levy
authors.forename: D
authors.initials: D
authors.lastname: Kondziolka
authors.forename: H
authors.initials: H
authors.lastname: Yonas
mesh_terms: D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000601:surgery; D003131:Combined Modality Therapy; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging; D016634:Radiosurgery; D012086:Reoperation; D014057:Tomography, X-Ray Computed