1. Title: How good is staged SRS for
large AVMs?
Macquarie Neurosurgery
Evidence Based Surgery presentation
Date: June 21, 2012
NJP
EBS presentation 1

2. Clinical case
• Recently we saw the results for surgical
treatment of SPM grade 4,5.
• Surgery Results are: 5% death, 20%
morbidity, 100% cure.
• SRS for these lesions is: 36% obliteration,
36% bleed for > 10cm3
• Can stage SRS do better?
EBS presentation 2

3. Clinical Example
EBS presentation 3

4. Searchable question (PICO format)
• What is the obliteration rate, bleed rate, side
effect rate for large AVMs treated by
STAGED SRS?
EBS presentation 4

5. Search strategy
• P: Patients with Large AVM
• I: Staged SRS
• C: surgery avm (Not searched here)
• O: obliteration, death, side effect, bleed
EBS presentation 5

6. Medline: 35 found, 24 kept.
EBS presentation 6

7. Embase – Using EMTree.
Found 20 kept 16
EBS presentation 7

8. Scopus: 55 found.
EBS presentation 8

9. Summary of papers
• Table
EBS presentation 9

10. Summary
• 35-66 % Obliteration. Mean 42%
• Not as many deaths as I expect, before
obliteration, after treatment.
EBS presentation 10

11. Conclusions
• Low side effects, low efficacy.
• IN those non-surgical patients, should we
given them SRS for a 33% chance of cure?
• If they fail, perhaps its becomes surgical?
EBS presentation 11

12. Kano
• 90% of cases are grade 4 or 5
• 17/47 = 36% obliterated after 10 years
• 8/47 = 17% died of bleeding
• ARE
EBS presentation 12

13. Proposal to study EBS?
• Compare our EBS strategy results to
published neurosurgery article results.
EBS presentation 13