The contemporary role of stereotactic radiosurgery for surgically inoperable cerebral arteriovenous malformations.

Abstract

Surgically inoperable cerebral arteriovenous malformations (AVMs), including deep-seated, large, and eloquently located lesions, remain difficult to manage because the cumulative risk of hemorrhage must be balanced against the morbidity of curative microsurgery. Contemporary stereotactic radiosurgery (SRS) has expanded beyond a salvage option into a precision-based strategy for selected high-risk AVMs. Volume-staged SRS enables biologically effective dosing for large nidus volumes while limiting exposure of eloquent brain tissue, and repeat SRS is increasingly recognized as part of planned longitudinal care rather than treatment failure. Comparative and propensity-adjusted observational studies suggest that SRS may achieve higher obliteration rates than standalone embolization in selected patients with eloquent or deep AVMs. Pre-radiosurgical embolization may remain appropriate for specific indications, including associated aneurysms, high-risk fistulous components, or nidus-volume reduction before staged treatment. Advances in the management of radiation-induced injury, including anti-vascular endothelial growth factor therapy and minimally invasive approaches for refractory necrosis, may provide additional management options for selected patients. This article synthesizes recent evidence and proposes an individualized framework that integrates anatomy, lifetime hemorrhage risk, radiosurgical strategy, and multidisciplinary expertise to support durable hemorrhage prevention while preserving neurological function.