title: Volume-staged versus dose-staged radiosurgery outcomes for large intracranial arteriovenous malformations.
abstract: OBJECTIVE
  The aim in this paper was to compare the outcomes of dose-staged and volume-staged stereotactic radio-surgery (SRS) in the treatment of large (> 10 cm(3)) arteriovenous malformations (AVMs).
  
  
  METHODS
  A systematic literature review was performed using PubMed. Studies written in the English language with at least 5 patients harboring large (> 10 cm(3)) AVMs treated with dose- or volume-staged SRS that reported post-treatment outcomes data were selected for review. Demographic information, radiosurgical treatment parameters, and post-SRS outcomes and complications were analyzed for each of these studies.
  
  
  RESULTS
  The mean complete obliteration rates for the dose- and volume-staged groups were 22.8% and 47.5%, respectively. Complete obliteration was demonstrated in 30 of 161 (18.6%) and 59 of 120 (49.2%) patients in the dose- and volume-staged groups, respectively. The mean rates of symptomatic radiation-induced changes were 13.5% and 13.6% in dose- and volume-staged groups, respectively. The mean rates of cumulative post-SRS latency period hemorrhage were 12.3% and 17.8% in the dose- and volume-staged groups, respectively. The mean rates of post-SRS mortality were 3.2% and 4.6% in dose- and volume-staged groups, respectively.
  
  
  CONCLUSIONS
  Volume-staged SRS affords higher obliteration rates and similar complication rates compared with dose-staged SRS. Thus, volume-staged SRS may be a superior approach for large AVMs that are not amenable to single-session SRS. Staged radiosurgery should be considered as an efficacious component of multimodality AVM management.
authors.affiliation: Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.
authors.forename: Shayan
authors.initials: S
authors.lastname: Moosa
authors.forename: Ching-Jen
authors.initials: CJ
authors.lastname: Chen
authors.forename: Dale
authors.initials: D
authors.lastname: Ding
authors.forename: Cheng-Chia
authors.initials: CC
authors.lastname: Lee
authors.forename: Srinivas
authors.initials: S
authors.lastname: Chivukula
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Chun-Po
authors.initials: CP
authors.lastname: Yen
authors.forename: Zhiyuan
authors.initials: Z
authors.lastname: Xu
authors.forename: Jason P
authors.initials: JP
authors.lastname: Sheehan
mesh_terms: D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D008297:Male; D039781:PubMed / Q000706:statistics & numerical data; D016634:Radiosurgery / Q000592:standards*; D016896:Treatment Outcome
keywords: AVM = arteriovenous malformation; GKRS = Gamma Knife radiosurgery; HSRT = hypofractionated stereotactic radiotherapy; RIC = radiation-induced change; SRS = stereotactic radiosurgery; arteriovenous malformation; dose-staged; review; staging; stereotactic radiosurgery; volume-staged