Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks

Figures & data

Table 1 Literature Review On Late RAEs (Studies With ≥ 100 patients)

Author	Year	N	Median Observation Period (y)	Definition Of Late RAEs	Incidence (Crude Or Cumulative Rate)	Risk Factors	Remarks/Treatment Modality
T. Hasegawa^Citation72	2019	189	11.3*	CF, CEH, RIT	7.2%/15 y (cumulative)	Larger nidus volume	All pediatric patients.
H. Hasegawa^Citation64	2018	581	11.8*	CF, CEH	7.6%/15 y (cumulative)	Diameter > 22 mm, lobar location, (Early edema, secondary SRS)^†	GKRS
Pomeraniec^Citation66	2018	1159	5.9 (w CF)/11.0 (wo CF)	CF	1.5% (crude)	Larger number of isocenters, early edema, longer follow-up	GKRS
Pollock^Citation68	2017	233	9.8	ND	12.5%/15 y (cumulative)	Early edema, nidus occlusion, SRS before April 1997	GKRS
Nakajima^Citation73	2016	404	4.9	CF, CEH	5.0% (crude)	No factor	GKRS
Matsuo^Citation67	2014	109	ND	CF	5.5% (crude)	NA	Linac-radiosurgery
Parkhutik^Citation62	2013	102	5.3	Radionecrosis	6.9% (crude)	Diameter > 3 cm, secondary SRS	GKRS
Pan^Citation74	2005	1203	See below^†	CF	3.6% (crude)	Addition of embolization, early edema	GKRS
Izawa^Citation63	2005	237	6.8*	CF	3.4% (crude)	Higher central dose, larger nidus volume, nidus occlusion, lobar location	GKRS

Notes: *Mean. ^†Observation period < 5 y, 674 patients; 5–10 y, 332 patients; 11–15 y, 167 patients; 16–23 y, 30 patients.

Abbreviations: AVM, arteriovenous malformation; CF, cyst formation; CEH, chronic encapsulated hematoma; GKRS, gamma knife radiosurgery; NA, not assessed; ND, not described; RAE, radiation adverse event; RIT, radiation-induced tumor; y, year(S); w, with; wo, without.

Table 2 Literature Review On Outcomes Of VSGKRS For Large AVMs (Studies With ≥ 15 patients)

Year	Author	N	Median Follow-Up Period (m)	Median Age At GKRS (y)	Median Prescription Dose (Gy)	Median Nidus Volume (mL)	Cases With Prior Hemorrhage	Obliteration Rate	Post-GKRS Hemorrhage Rate	Morbidity	Mortality
2019	El-Shehaby^Citation98	29	43*	24*	18*	16*	58.3%	62.5% (CR)	2%/y	3.4% (CR)	0%
2018	Kano^Citation97	60	ND	30	16	11.6 (1st), 10.6 (2nd)	43%	44%/10 y	25.2%/10 y	7% (CR)	16.7%/10 y
2017	Pollock^Citation101	34	98.4	31	16	22.2	35%	75%/7 y	4.6%/y	6% (CR)	6% (CR)
2017	Nagy^Citation103	44†	> 48	37	17.5	19.7	44%	61.4%/4 y	3.2%/y (wo HoH), 5.6%/y (w HoH)	6.5% (CR)	6% (CR)
2016	Hanakita^Citation89	18	53	33	16	38	67%	35%/5 y	3.9%/y	11% (CR)	5.5% (CR)
2016	Park^Citation94**	45	104.9*	29*	13–17	20.4*	22.2%	64.4% (CR)	11.1% (CR)	ND	3% (CR)
2016	Seymour^Citation102	69	57.6–103.2	34	15.5–17.0	18.9–27.3	35–39%	21–68%/5 y (including near complete obliteration)	5.6%/y	3–16% (CR)	13–21% (CR)
2016	Franzin^Citation99	20	45*	38	20	15.9	30%	20% (75% reduction)	10% (CR)	5% (CR)	ND
2012	Huang^Citation100	18	> 36‡	35	15	22.9	55.6%	89%/10 y	31%/5 y	5.6% (CR)	5.6% (CR)

Notes: *Mean. **The interval of each GKRS session was > 2 years. ^†This is a study on 76 patients but the outcome analyses were performed only for the 44 patients who had follow-up data. ^‡Sixteen out of 18 patients completed > 36 months of follow-up.

Abbreviations: AVM, arteriovenous malformation; BS, brainstem; CR, crude rate; GKRS, gamma knife radiosurgery; HoH, history of hemorrhage; m, month(s); ND, not described; y, year(s); VSGKRS, volume-staged gamma knife radiosurgery; w, with; wo, without.

Table 3 Literature Review On Outcomes Of A Combination Of GKRS And Embolization (Studies With ≥ 25 patients)

Year	Author	N	Material For Embolization	Median Prescription Dose (Gy)	Median Nidus Volume (mL)	Cases With Prior Hemorrhage	Obliteration Rate (As Compared To Non-Embolized Cohort)	Post-GKRS Hemorrhage Rate	Study Design
2017	Miyachi^Citation111	73	NBCA (100%)	ND	Pre, 13.8*	59%	CR, 60.3%	CR, 4.1%	Multicenter single arm retrospective analysis
2017	Strauss^Citation112	35	Onyx (100%)	20	Pre, 12.2*; Post, 1.8*	40%	CR, 51.4%	CR, 2.9%	Single arm retrospective analysis
2016	Huo^Citation113	162	Onyx (60%), NBCA (37%), silk/coil (2%)	16.0	Pre, 14.3; Post, 10.9	48.1%	CR, 56.8%	1.71%/y	Single arm retrospective analysis
2015	Oermann^Citation104	242	NBCA (79%), coil (13%), Onyx (9%)	20	Post, 4.6	50%	30.9%/5 y (worse)	2.0%/y	Matched cohort analysis (emboli + GKRS vs GKRS only)
2015	Lee^Citation105	25	Onyx (100%)	22	Post, 3.5	36%	34.1%/4 y (no difference)	CR, 4%	Matched cohort analysis (emboli + GKRS vs GKRS only)
2015	Xiaochuan^Citation107	46**	ND (mostly Onyx)	16.3	Pre, 14.1	50%	CR, 28.2%	1.66%/y	Retrospective analysis focusing on target embolization with GKRS
2012	Schwyzer^Citation108	215	NBCA (66%), coil (11%), silk (2%)	19.6*	Post, 4.7*	42.8%	CR, 33% (worse)	CR, 6.08%	Retrospective comparison between emboli + GKRS vs GKRS only
2012	Kano^Citation109	120	PVA (17%), NBCA/isobutyl 2-cyanoacrylate (44%), coil (8%), ND (32%)	18	Post, 6.6	53.3%	55%/5 y (worse)	2.7%/y	Matched cohort analysis (emboli + GKRS vs GKRS only)
2000	Miyachi^Citation110	37	NBCA (100%)	ND	Pre, 21.9*; Post, 3.9*	40.5%	CR, 49% (for > 90% occlusion)	CR, 5.4%	Single arm retrospective analysis

Notes: *Mean. **Forty-six out of 86 patients had follow-up data.

Abbreviations: CR, crude rate; GKRS, gamma knife radiosurgery; NBCA, n-butyl cyanoacrylate; ND, not described; Post, post-embolization; Pre, pre-embolization; PVA, polyvinyl alcohol particle; y, year(s).

Table 4 Literature Review On Outcomes Of ARUBA-Eligible Patients (Studies With ≥ 100 patients)

Year	Author	N	Median Follow-Up Period (m)	Median Age At GKRS (y)	Median Nidus Volume (mL)	Obliteration Rate	Stroke Or Death Rate
2019	Karlsson^Citation136	1351	60	41	5	61% (CR)	5.8%/2 y (stroke), 1.4%/2 y (death)
2018	Tonetti^Citation134	233	100.8	42*	ND	72% (CR)	0.8%/y
2017	Ding^Citation133	232	90.5*	42*	2.1*	72%/5 y	10.3% (CR for stroke or death), 1.0%/y (stroke)
2016	Ding^Citation131	509	86*	40*	3.0*	75% (CR)	0.9%/y (stroke), 1.0–2.9% (death, depending on whether the unknown causes of death were related to AVM or not)
2016	Hanakita^Citation135	240	62	39	4.3	73%/6 y	1.1%/y (stroke)
2013	Pollock^Citation132	174	64	42.5	5.6	69.7% (CR)	10.3%/5 y (stroke or death)

Notes: *Mean.

Abbreviations: ARUBA, A Randomised trial of Unruptured Brain Arteriovenous malformations; CR, crude rate; m = month(s); GKRS, gamma knife radiosurgery; ND, not described; y, year(s).

Table 5 Literature Review Describing Stereotactic Radiosurgery For DAVFs (Studies With ≥ 20 patients)

Year	Author	N	Median Prescription Dose (Gy)	Cases With Embolization	Cases With Prior Hemorrhage	Cases With CVD	Crude Obliteration Rate	Hemorrhage Rate	RAE Rate	Factors Associated With Successful Obliteration	Remarks
2019	Starke^Citation165	114	Mean, 21.8	47%	24%	52%	68%	0.9%/year	3.5%	Female sex, absence of venous ectasia, CS location	Multicenter study
2018	Tonettii^Citation161	42	20	67%	31%	100%	64%	0.8%/year	/	/	All cases had CVD
2018	Chen^Citation162	27*	Mean, 20	63%	44%	63%	63%	3.3%/year	/	None	All cases had high-risk features
2016	Park^Citation163	20	Mean, 16.8	0%	5%	60%	90%	0%	5%	/	No cases had prior embolization
2013	Pan^Citation50	264	Mean, 17.2	13%	/	45%†	66%	0.8%	0.4%	/	/
2012	Hanakita^Citation152	22	20	45%	27%	68%	55%	0%	0%	Absence of CVD, prior hemorrhage, volume < 1.5 mL, Cognard type III/IV	/
2010	Cifarelli^Citation154	55	21	65%	36%	71%	54%	5.4%	1.8%	Absence of CVD, Borden type I**	/
2010	Yang^Citation153	40	20	30%	18%	50%	73%	2.5%	0%	CS location**	/
2006	Soderman^Citation155	49	Mean, 23	17%	39%	69%	68%	4.0%	2.0%	/	/
2001	Friedman^Citation157	23	18	87%‡	9%	17%	41%§	0%	0%	None	/
1999	Pollock^Citation158	20	20	65%‡	0%	20%	65%	0%	0%¶	/	CS DAVF only

Notes: *The entire cohort includes 41 patients but follow-up data were available for only 27. ^†52 of the 115 patients with non-CS DAVFs had CVD. **Results from univariate analyses; multivariate analysis was not performed. ^‡Planned post-radiosurgical embolization was included. ^§Calculated from data not including patients lacking follow-up angiography (n = 6). ^¶One recurrence of visual symptoms was noted.

Abbreviations: CS, cavernous sinus; CVD, cortical venous drainage; DAVF, dural arteriovenous fistula; RAE, radiation-induced adverse event; TS, transverse-sigmoid.

Table 6 Literature Review Of Recent Studies Describing Stereotactic Radiosurgery For CMs

Year	Author	N	Mean F/U (Month)	Mean Age (Year)	Mean Diameter (mm)	Mean Volume (mL)	Location	Mean Prescription Dose (Gy)	Hemorrhage rate		Rate Of New Neurological Deficits
									Before GKRS	After GKRS
2018	Park^Citation186	45	112	37	NA	1.8	BS	13	40%/y	3.3%/y (<2y), 1.5%/y (2–5y), 4.6%/y (>5y)	2.6%
2018	Jacobs^Citation194	76	NA	42	NA	0.66**	BS	15**	31%/y	4%/y	9%
2018	Sheen^Citation195	81	79**	39	NA	1.0	Any	14	NA	7.5%	NA
2016	Liu^Citation187	43	36	42	NA	0.44	BS	12	25%/y	3.9%/y (<2y), 1.9%/y (>2y)	2.3%
2015	Kida^Citation185	298	68	39	15	N/A	BS, Thal, BGL, others	15	21%/y	7.4%/y (<2y), 2.8%/y (>2y)	6.7%
2012	Lee^Citation189	49	41	39	32	3.2	BS	11	31%/y	4.3%/y (<2y), 3.6%/y (>2y)	4.1%
2010	Lunsford^Citation190	103	24–240*	39	NA	1.3**	BS, Thal, BGL, others	16**	33%/y	11%/y (<2y), 1.1%/y (>2y)	14%
2010	Nagy^Citation191	113	48	37	NA	0.34–0.83	BS, Thal, BGL	12	31%/y^† 2.2%/y	15%/y (<2y) ^†, 2.4%/y (>2y) ^† 5.1%/y (<2y) ^‡, 1.3%/y (>2y) ^‡	7.3%
2010	Monaco^Citation193	68	62	41	NA	1.2	BS	16	32%/y	8.2%/y (<2y), 1.4%/y (>2y)	12%
2009	Kida^Citation192	84	55	38	14	N/A	BS, Thal, BGL	13	NA	9.5%/y (<1y), 4.7%/y (1–2y)	3.2%
2002	Hasegawa^Citation181	82	59	38	NA	1.9	BS, Thal, BGL, others	16	34%/y	12%/y (<2y), 0.76%/y (<2y)	7.3%

Notes: *Detailed data on the median or mean value not provided. **Median. ^†Results of high-risk group. ^‡Results of low-risk group

Abbreviations: BGL, basal ganglia; BS, brainstem; F/U, follow up; GKRS, gamma knife; NA, not assessed; Thal, thalamus.

Hasegawa T, Kato T, Naito T, et al. Long-term outcomes for pediatric patients with brain arteriovenous malformations treated with gamma knife radiosurgery, Part 2: the incidence of cyst formation, encapsulated hematoma, and radiation-induced tumor. World Neurosurg. 2019;126:e1526–e1536. doi:10.1016/j.wneu.2019.03.17730922905

 PubMed Web of Science ®Google Scholar

Hasegawa H, Hanakita S, Shin M, et al. A comprehensive study of symptomatic late radiation-induced complications after radiosurgery for brain arteriovenous malformation: incidence, risk factors, and clinical outcomes. World Neurosurg. 2018;116:e556–e565. doi:10.1016/j.wneu.2018.05.03829772363

 PubMed Web of Science ®Google Scholar

Pomeraniec IJ, Ding D, Starke RM, et al. Delayed cyst formation after stereotactic radiosurgery for brain arteriovenous malformations. J Neurosurg. 2017;1–10.

 Google Scholar

Pollock BE, Link MJ, Branda ME, Storlie CB. Incidence and management of late adverse radiation effects after arteriovenous malformation radiosurgery. Neurosurgery. 2017. doi:10.1093/neuros/nyx010

 Web of Science ®Google Scholar

Nakajima H, Yamanaka K, Ishibashi K, Iwai Y. Delayed cyst formations and/or expanding hematomas developing after Gamma Knife surgery for cerebral arteriovenous malformations. J Clin Neurosci. 2016;33:96–99. doi:10.1016/j.jocn.2016.01.04427430414

 PubMed Web of Science ®Google Scholar

Matsuo T, Kamada K, Izumo T, Hayashi N, Nagata I. Cyst formation after linac-based radiosurgery for arteriovenous malformation: examination of predictive factors using magnetic resonance imaging. Clin Neurol Neurosurg. 2014;121:10–16. doi:10.1016/j.clineuro.2014.03.00624793466

 PubMed Web of Science ®Google Scholar

Parkhutik V, Lago A, Aparici F, et al. Late clinical and radiological complications of stereotactical radiosurgery of arteriovenous malformations of the brain. Neuroradiology. 2013;55(4):405–412. doi:10.1007/s00234-012-1115-823183855

 PubMed Web of Science ®Google Scholar

Pan HC, Sheehan J, Stroila M, Steiner M, Steiner L. Late cyst formation following gamma knife surgery of arteriovenous malformations. J Neurosurg. 2005;102(s_supplement):124–127. doi:10.3171/jns.2005.102.s_supplement.012415662794

 PubMed Web of Science ®Google Scholar

Izawa M, Hayashi M, Chernov M, et al. Long-term complications after gamma knife surgery for arteriovenous malformations. J Neurosurg. 2005;102(s_supplement):34–37. doi:10.3171/sup.2005.102.s_supplement.003415662777

 PubMed Web of Science ®Google Scholar

El-Shehaby AMN, Reda WA, Abdel Karim KM, Emad Eldin RM, Nabeel AM, Tawadros SR. Volume-staged Gamma Knife radiosurgery for large brain arteriovenous malformation. World Neurosurg. 2019. doi:10.1016/j.wneu.2019.08.065

 PubMed Web of Science ®Google Scholar

Kano H, Flickinger JC, Nakamura A, et al. How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations. J Neurosurg. 2018;1–8.

 Google Scholar

Pollock BE, Link MJ, Stafford SL, Lanzino G, Garces YI, Foote RL. Volume-staged stereotactic radiosurgery for intracranial arteriovenous malformations: outcomes based on an 18-year experience. Neurosurgery. 2017;80(4):543–550. doi:10.1093/neuros/nyw10728362923

 PubMed Web of Science ®Google Scholar

Nagy G, Grainger A, Hodgson TJ, et al. Staged-volume radiosurgery of large arteriovenous malformations improves outcome by reducing the rate of adverse radiation effects. Neurosurgery. 2017;80(2):180–192. doi:10.1227/NEU.000000000000121228173493

 PubMed Web of Science ®Google Scholar

Hanakita S, Shin M, Koga T, Igaki H, Saito N. Outcomes of volume-staged radiosurgery for cerebral arteriovenous malformations larger than 20 cm(3) with more than 3 years of follow-up. World Neurosurg. 2016;87:242–249. doi:10.1016/j.wneu.2015.12.02026723283

 PubMed Web of Science ®Google Scholar

Park HR, Lee JM, Kim JW, et al. Time-staged gamma knife stereotactic radiosurgery for large cerebral arteriovenous malformations: a preliminary report. PLOS ONE. 2016;11(11):e0165783. doi:10.1371/journal.pone.016578327806123

 PubMed Web of Science ®Google Scholar

Seymour ZA, Sneed PK, Gupta N, et al. Volume-staged radiosurgery for large arteriovenous malformations: an evolving paradigm. J Neurosurg. 2016;124(1):163–174. doi:10.3171/2014.12.JNS14130826140495

 PubMed Web of Science ®Google Scholar

Franzin A, Panni P, Spatola G, et al. Results of volume-staged fractionated Gamma Knife radiosurgery for large complex arteriovenous malformations: obliteration rates and clinical outcomes of an evolving treatment paradigm. J Neurosurg. 2016;125(Suppl 1):104–113. doi:10.3171/2016.7.GKS16154927903180

 PubMed Web of Science ®Google Scholar

Huang PP, Rush SC, Donahue B, et al. Long-term outcomes after staged-volume stereotactic radiosurgery for large arteriovenous malformations. Neurosurgery. 2012;71(3):632–643. discussion 643–634. doi:10.1227/NEU.0b013e31825fd24722710381

 PubMed Web of Science ®Google Scholar

Miyachi S, Izumi T, Satow T, et al. Effectiveness of preradiosurgical embolization with NBCA for arteriovenous malformations - retrospective outcome analysis in a japanese registry of 73 patients (J-REAL study). Neurointervention. 2017;12(2):100–109. doi:10.5469/neuroint.2017.12.2.10028955512

 PubMedGoogle Scholar

Strauss I, Haim O, Umansky D, et al. Impact of onyx embolization on radiosurgical management of cerebral arteriovenous malformations: treatment and outcome. World Neurosurg. 2017;108:656–661. doi:10.1016/j.wneu.2017.08.18828890009

 PubMed Web of Science ®Google Scholar

Huo X, Jiang Y, Lv X, Yang H, Zhao Y, Li Y. Gamma Knife surgical treatment for partially embolized cerebral arteriovenous malformations. J Neurosurg. 2016;124(3):767–776. doi:10.3171/2015.1.JNS14271126252461

 PubMed Web of Science ®Google Scholar

Oermann EK, Ding D, Yen CP, et al. Effect of prior embolization on cerebral arteriovenous malformation radiosurgery outcomes: a case-control study. Neurosurgery. 2015;77(3):406–417. discussion 417. doi:10.1227/NEU.000000000000077225875580

 PubMed Web of Science ®Google Scholar

Lee CC, Chen CJ, Ball B, et al. Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study. J Neurosurg. 2015;123(1):126–135. doi:10.3171/2014.12.JNS14143725658780

 PubMed Web of Science ®Google Scholar

Xiaochuan H, Yuhua J, Xianli L, Hongchao Y, Yang Z, Youxiang L. Targeted embolization reduces hemorrhage complications in partially embolized cerebral AVM combined with gamma knife surgery. Interv Neuroradiol. 2015;21(1):80–87. doi:10.1177/INR-2014-1009025934780

 PubMed Web of Science ®Google Scholar

Schwyzer L, Yen CP, Evans A, Zavoian S, Steiner L. Long-term results of gamma knife surgery for partially embolized arteriovenous malformations. Neurosurgery. 2012;71(6):1139–1147. discussion 1147–1138. doi:10.1227/NEU.0b013e318272028022986603

 PubMed Web of Science ®Google Scholar

Kano H, Kondziolka D, Flickinger JC, et al. Stereotactic radiosurgery for arteriovenous malformations after embolization: a case-control study. J Neurosurg. 2012;117(2):265–275. doi:10.3171/2012.4.JNS11193522631689

 PubMed Web of Science ®Google Scholar

Miyachi S, Negoro M, Okamoto T, et al. Embolisation of cerebral arteriovenous malformations to assure successful subsequent radiosurgery. J Clin Neurosci. 2000;7(Suppl 1):82–85. doi:10.1054/jocn.2000.071811013105

 PubMed Web of Science ®Google Scholar

Karlsson B, Jokura H, Yang HC, et al. The NASSAU (New ASSessment of cerebral Arteriovenous Malformations yet Unruptured) Analysis: are the results from the ARUBA trial also applicable to unruptured arteriovenous malformations deemed suitable for Gamma Knife surgery? Neurosurgery. 2019;85(1):E118–E124. doi:10.1093/neuros/nyy39130295870

 PubMed Web of Science ®Google Scholar

Tonetti DA, Gross BA, Atcheson KM, et al. The benefit of radiosurgery for ARUBA-eligible arteriovenous malformations: a practical analysis over an appropriate follow-up period. J Neurosurg. 2018;128(6):1850–1854. doi:10.3171/2017.1.JNS16296228665253

 PubMed Web of Science ®Google Scholar

Ding D, Starke RM, Kano H, et al. Stereotactic radiosurgery for ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-Eligible Spetzler-Martin Grade I and II arteriovenous malformations: a multicenter study. World Neurosurg. 2017;102:507–517. doi:10.1016/j.wneu.2017.03.06128344176

 PubMed Web of Science ®Google Scholar

Ding D, Starke RM, Kano H, et al. Radiosurgery for cerebral arteriovenous malformations in a randomized trial of unruptured brain Arteriovenous Malformations (ARUBA)-eligible patients: a multicenter study. Stroke. 2016;47(2):342–349. doi:10.1161/STROKEAHA.115.01140026658441

 PubMed Web of Science ®Google Scholar

Hanakita S, Shin M, Koga T, Igaki H, Saito N. Risk reduction of cerebral stroke after stereotactic radiosurgery for small unruptured brain arteriovenous malformations. Stroke. 2016;47(5):1247–1252. doi:10.1161/STROKEAHA.116.01313227073242

 PubMed Web of Science ®Google Scholar

Pollock BE, Link MJ, Brown RD. The risk of stroke or clinical impairment after stereotactic radiosurgery for ARUBA-eligible patients. Stroke. 2013;44(2):437–441. doi:10.1161/STROKEAHA.112.67023223287780

 PubMed Web of Science ®Google Scholar

Starke RM, McCarthy DJ, Chen CJ, et al. Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium. J Neurosurg. 2019;1–8.

 Google Scholar

Tonetti DA, Gross BA, Jankowitz BT, et al. Reconsidering an important subclass of high-risk dural arteriovenous fistulas for stereotactic radiosurgery. J Neurosurg. 2018;1–5.

 Google Scholar

Chen CJ, Buell TJ, Diamond J, et al. Stereotactic radiosurgery for high-grade intracranial dural arteriovenous fistulas. World Neurosurg. 2018;116:e640–e648. doi:10.1016/j.wneu.2018.05.06229777886

 PubMed Web of Science ®Google Scholar

Park KS, Kang DH, Park SH, Kim YS. The efficacy of gamma knife radiosurgery alone as a primary treatment for intracranial dural arteriovenous fistulas. Acta Neurochir (Wien). 2016;158(4):821–828. doi:10.1007/s00701-016-2720-926858208

 PubMed Web of Science ®Google Scholar

Cohen-Inbar O, Lee CC, Xu Z, Schlesinger D, Sheehan JP. A quantitative analysis of adverse radiation effects following Gamma Knife radiosurgery for arteriovenous malformations. J Neurosurg. 2015;123(4):945–953. doi:10.3171/2014.10.JNS14226425909572

 PubMed Web of Science ®Google Scholar

Hanakita S, Koga T, Shin M, Shojima M, Igaki H, Saito N. Role of Gamma Knife surgery in the treatment of intracranial dural arteriovenous fistulas. J Neurosurg. 2012;117(Suppl):158–163. doi:10.3171/2012.7.GKS1296723205804

 PubMed Web of Science ®Google Scholar

Cifarelli CP, Kaptain G, Yen CP, Schlesinger D, Sheehan JP. Gamma knife radiosurgery for dural arteriovenous fistulas. Neurosurgery. 2010;67(5):1230–1235. discussion 1235. doi:10.1227/NEU.0b013e3181eff6f720871448

 PubMed Web of Science ®Google Scholar

Yang HC, Kano H, Kondziolka D, et al. Stereotactic radiosurgery with or without embolization for intracranial dural arteriovenous fistulas. Neurosurgery. 2010;67(5):1276–1283. discussion 1284–1275. doi:10.1227/NEU.0b013e3181ef3f2220871453

 PubMed Web of Science ®Google Scholar

Soderman M, Edner G, Ericson K, et al. Gamma knife surgery for dural arteriovenous shunts: 25 years of experience. J Neurosurg. 2006;104(6):867–875. doi:10.3171/jns.2006.104.6.86716776329

 PubMed Web of Science ®Google Scholar

Friedman JA, Pollock BE, Nichols DA, Gorman DA, Foote RL, Stafford SL. Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses. J Neurosurg. 2001;94(6):886–891. doi:10.3171/jns.2001.94.6.088611409515

 PubMed Web of Science ®Google Scholar

Pollock BE, Nichols DA, Garrity JA, Gorman DA, Stafford SL. Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae. Neurosurgery. 1999;45(3):459–466. discussion 466–457. doi:10.1097/00006123-199909000-0000810493367

 PubMed Web of Science ®Google Scholar

Park K, Kim JW, Chung HT, Paek SH, Kim DG. Long-term outcome of Gamma Knife radiosurgery for symptomatic brainstem cavernous malformation. World Neurosurg. 2018;116:e1054–e1059. doi:10.1016/j.wneu.2018.05.16429864574

 PubMed Web of Science ®Google Scholar

Jacobs R, Kano H, Gross BA, Niranjan A, Monaco EA 3rd, Lunsford LD. Defining long-term clinical outcomes and risks of stereotactic radiosurgery for brainstem cavernous malformations. World Neurosurg. 2018.

 Google Scholar

Sheen JJ, Lee DH, Lee DH, Song Y, Kwon DH. Long-term outcome of gamma knife radiosurgery for brain cavernoma: factors associated with subsequent De Novo Cavernoma formation. World Neurosurg. 2018;120:e17–e23. doi:10.1016/j.wneu.2018.07.04630026166

 PubMed Web of Science ®Google Scholar

Liu HB, Wang Y, Yang S, Gong FL, Xu YY, Wang W. Gamma knife radiosurgery for brainstem cavernous malformations. Clin Neurol Neurosurg. 2016;151:55–60. doi:10.1016/j.clineuro.2016.09.01827794267

 PubMed Web of Science ®Google Scholar

Kida Y, Hasegawa T, Iwai Y, et al. Radiosurgery for symptomatic cavernous malformations: a multi-institutional retrospective study in Japan. Surg Neurol Int. 2015;6(Suppl 5):S249–257. doi:10.4103/2152-7806.15707126005588

 PubMedGoogle Scholar

Lee CC, Pan DH, Chung WY, et al. Brainstem cavernous malformations: the role of Gamma Knife surgery. J Neurosurg. 2012;117(Suppl):164–169. doi:10.3171/2012.8.GKS12106623205805

 PubMed Web of Science ®Google Scholar

Lunsford LD, Khan AA, Niranjan A, Kano H, Flickinger JC, Kondziolka D. Stereotactic radiosurgery for symptomatic solitary cerebral cavernous malformations considered high risk for resection. J Neurosurg. 2010;113(1):23–29. doi:10.3171/2010.1.JNS08162620170299

 PubMed Web of Science ®Google Scholar

Nagy G, Razak A, Rowe JG, et al. Stereotactic radiosurgery for deep-seated cavernous malformations: a move toward more active, early intervention. Clinical article. J Neurosurg. 2010;113(4):691–699. doi:10.3171/2010.3.JNS09115620433275

 PubMed Web of Science ®Google Scholar

Monaco EA, Khan AA, Niranjan A, et al. Stereotactic radiosurgery for the treatment of symptomatic brainstem cavernous malformations. Neurosurg Focus. 2010;29(3):E11. doi:10.3171/2010.7.FOCUS10151

 PubMed Web of Science ®Google Scholar

Kida Y. Radiosurgery for cavernous malformations in basal ganglia, thalamus and brainstem. Prog Neurol Surg. 2009;22:31–37.18948717

 PubMedGoogle Scholar

Hasegawa T, McInerney J, Kondziolka D, Lee JY, Flickinger JC, Lunsford LD. Long-term results after stereotactic radiosurgery for patients with cavernous malformations. Neurosurgery. 2002;50(6):1190–1197. discussion 1197–1198. doi:10.1097/00006123-200206000-0000312015835

 PubMed Web of Science ®Google Scholar