title: Stereotactic radiosurgery with neoadjuvant embolization of larger arteriovenous malformations: an institutional experience.
abstract: OBJECTIVE
  This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs.
  
  
  METHODS
  Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011.
  
  
  RESULTS
  The median volume of AVM in this series was 28 cm(3) and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9-136 months). Overall procedural complications occurred in 14 patients. There were 13 minor neurologic complications and 1 major complication (due to embolization) while four patients had posttreatment hemorrhage. Thirty-eight patients (40%) were cured radiographically. The postradiosurgery actuarial rate of obliteration was 45% at 5 years, 56% at 7 years, and 63% at 10 years. In multivariate analysis, larger AVM size, deep venous drainage, and the increasing number of embolization/SRS sessions were negative predictors of obliteration. The number of embolizations correlated positively with the number of stereotactic radiosurgeries (P < 0.005).
  
  
  CONCLUSIONS
  Multimodality endovascular and radiosurgical approach is an efficacious treatment strategy for large AVM.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Dalyai
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Thana
authors.initials: T
authors.lastname: Theofanis
authors.affiliation: Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: George
authors.initials: G
authors.lastname: Ghobrial
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: L
authors.initials: L
authors.lastname: Fernando Gonzalez
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Gordon
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Rosenwasser
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
authors.forename: Stavropoula I
authors.initials: SI
authors.lastname: Tjoumakaris
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001165:Arteriovenous Malformations / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004621:Embolization, Therapeutic; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D016634:Radiosurgery; D013238:Stereotaxic Techniques; D013997:Time Factors; D055815:Young Adult