Worse Outcomes after Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Retrospective Matched-Cohort Study

Dale Ding, Zhiyuan Xu, Han Hsun Shih, Robert M. Starke, Chun Po Yen, Or Cohen-Inbar, Jason P. Sheehan

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


BACKGROUND: Incompletely obliterated cerebral arteriovenous malformations (AVMs) after initial treatment with stereotactic radiosurgery (SRS) can be treated with a repeat session of SRS. However, the relative efficacy of repeat vs initial SRS is not well specified. OBJECTIVE: To retrospectively compare in matched cohorts the outcomes of repeat vs initial SRS for the treatment of matched cohorts with angioarchitecturally similar AVMs. METHODS: We studied a data set of patients with AVM treated with radiosurgery during the period spanning 1989 to 2013. Patients with AVM who underwent repeat SRS with radiologic follow-up of ≥2 years or nidus obliteration were identified for the study and matched, in a 1:1 fashion that was blinded to outcome, to patients with previously untreated AVMs who underwent initial SRS. Statistical analyses were performed to compare the outcomes after repeat vs initial SRS. RESULTS: The matching approach resulted in 84 patients for the repeat and the initial SRS cohort (mean margin doses, 20.7 and 20.9 Gy, respectively; P .74). In the repeat SRS cohort, obliteration was achieved in 67%; the radiologic, symptomatic, and permanent radiation-induced change rates were 35%, 10%, and 4%, respectively; and the post-SRS hemorrhage rate was 3.1%/y. Compared with the initial SRS cohort, the repeat SRS cohort had significantly lower obliteration rates (P .04) and higher post-SRS hemorrhage rates (P .04). The radiation-induced change rates of the 2 cohorts were not significantly different. CONCLUSION: Repeat SRS yields considerably poorer outcomes than initial SRS for angioarchitecturally comparable AVMs. Further studies in AVM radiobiology and vascular structure are necessary to elucidate this potentially differential response. Abbreviations: AVM, arteriovenous malformation RIC, radiation-induced change RBAS, radiosurgery-based arteriovenous malformation score SRS, stereotactic radiosurgery VRAS, Virginia radiosurgery AVM scale.

Original languageEnglish (US)
Pages (from-to)690-700
Number of pages11
Issue number5
StatePublished - Nov 1 2016
Externally publishedYes


  • Gamma Knife
  • Intracranial arteriovenous malformations
  • Intracranial hemorrhages
  • Radiosurgery
  • Repeat
  • Stroke
  • Vascular malformations

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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