High importance
Sep 20, 2026
To evaluate the role of stereotactic radiosurgery (SRS) in the management of surgically inoperable cerebral arteriovenous malformations (AVMs) and to propose an individualized treatment framework.
Review of contemporary strategies for SRS, including volume-staged SRS and comparison of outcomes with standalone embolization versus SRS.
SRS has shown higher obliteration rates compared to embolization in selected patients. Advances in managing radiation-induced injury have expanded treatment options, and repeat SRS is increasingly viewed as part of ongoing care rather than a failure.
The approach may not be suitable for all AVM types; detailed patient selection and specific procedural guidelines are necessary to optimize outcomes. Additional research is needed to standardize treatment protocols and assess long-term effects.
Improving management strategies for inoperable AVMs can lead to better long-term outcomes and reduced hemorrhage risks, ultimately enhancing patient quality of life and neurological function.
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.