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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Volume-Staged Stereotactic Radiosurgery in Pediatric Patients With Large Brain Arteriovenous Malformations: An
Bardia Hajikarimloo1, Salem M Tos1, Robert Ferguson1
1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
Insights
Volume-staged stereotactic radiosurgery (VS-SRS) offers a safe option for pediatric large-volume brain arteriovenous malformations (AVMs). This approach achieves durable nidus control with acceptable toxicity in a challenging patient group.
Area of Science:
- Neurosurgery
- Radiation Oncology
- Pediatric Neurology
Background:
- Pediatric large-volume brain arteriovenous malformations (AVMs) present significant risks of hemorrhage and neurological deficits.
- Single-session stereotactic radiosurgery (SRS) is often limited by dose-volume toxicity concerns in large AVMs.
- Volume-staged SRS (VS-SRS) allows for dose fractionation, potentially improving safety and efficacy for large AVMs in children.
Purpose of the Study:
- To evaluate the outcomes of VS-SRS for treating large-volume AVMs in pediatric patients.
- To assess the safety and efficacy of VS-SRS in a pediatric population with limited existing evidence.
Main Methods:
- A multicenter retrospective cohort study included 103 pediatric patients (<21 years) with AVMs >10 cm3 treated with VS-SRS.
- Data collected included clinical and radiological outcomes such as obliteration rates, hemorrhage events, and permanent radiation-induced changes (RIC).
Main Results:
- The median nidus volume was 18.2 cm3, with a median prescription dose of 17 Gy per stage.
- Obliteration was achieved in 40.8% of patients, with 5-year actuarial obliteration rates of 29%.
- Hemorrhage occurred in 16.5% of patients, and permanent RIC was observed in 8.7% during follow-up.
Conclusions:
- VS-SRS is a viable and relatively safe treatment option for pediatric large-volume AVMs when other curative options are not feasible.
- Delivering ≥17 Gy per stage with treatment volumes <15 cm3 supports sustained nidus control and manageable toxicity.
- VS-SRS is a crucial component in the multidisciplinary management of pediatric large-volume AVMs.
Background And Objectives:
Pediatric large-volume brain arteriovenous malformations (AVMs) carry a substantial lifelong hemorrhage risk, neurological symptoms, and treatment morbidity. Single-session stereotactic radiosurgery (SRS) is often unsuitable due to constraints on dose-volume toxicity. Volume-staged SRS (VS-SRS) enables sequential dosing of large nidus volumes, potentially enhancing safety while maintaining efficacy. Evidence in children remains limited. We aimed to evaluate outcomes of VS-SRS for large AVMs in pediatric patients.
Methods:
A multicenter retrospective cohort was assembled from 21 centers, including patients aged younger than 21 years treated with VS-SRS for AVMs >10 cm3. Clinical and radiological end points included obliteration, hemorrhage, and permanent symptomatic radiation-induced changes (RIC).
Results:
A total of 103 patients were included (median age 14 years; IQR, 12-17). The median nidus volume at first stage was 18.2 cm3 (IQR, 12.3-25.6). Median prescription dose per stage was 17 Gy (IQR, 16-18). The median clinical follow-up from the first stage was 57.5 months (IQR, 25-138). Obliteration occurred in 42 of 103 patients (40.8%), with actuarial rates of 6.9% (95% CI: 2.8-14) at 3 years and 29% (95% CI: 20-39) at 5 years. Hemorrhage occurred in 17 of 103 patients (16.5%) during follow-up, and permanent RIC was observed in 9 of 103 patients (8.7%).
Conclusion:
VS-SRS is a reasonably safe, selected option for pediatric large-volume AVMs when microsurgical or endovascular cure is not feasible or prudent. Delivering ≥17 Gy per stage while limiting each treatment volume to <15 cm3 supports durable nidus control with acceptable toxicity. VS-SRS represents a key modality in multidisciplinary management of this historically difficult-to-treat population.
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