脑动静脉畸形血管构筑学因素与癫疒间的关系及其栓塞治疗效果的研究

目的探讨脑动静脉畸形(AVM)相关血管构筑学因素(AVM的大小、位置、供血动脉)与癫发作的关系以及血管内栓塞治疗的效果。方法采用数字减影血管造影(DSA)对95例脑AVM患者进行全脑血管造影,比较不同AVM大小、位置及供血动脉支数患者的癫疒间发生率。观察血管内注射NBCA或ONYX胶进行AVM栓塞的临床疗效。结果脑AVM3～6cm、>6cm患者的癫疒间发生率(52.5%、57.1%)明显高于<3cm的患者(0)(均P<0.01);AVM位于大脑皮质患者的癫疒间发生率显著高于位于基底节、后颅窝的患者(均P<0.01);不同供血动脉支数患者的癫发生率差异无显著性(均P>0.05);本组43例有癫疒间发作患者,AVM栓塞术后20例症状消失,11例明显改善,总有效率72.1%。结论脑AVM的大小及位置与癫疒间有密切关系,供血动脉的支数与癫疒间发作无关;血管内栓塞治疗AVM的效果较好。     

脑动静脉畸形破裂出血并血肿形成的手术治疗

目的探讨脑动静脉畸形(AVM)破裂出血并血肿形成手术治疗的临床疗效。方法回顾性分析40例该病患者的临床特点、影像学特征及手术治疗效果。结果本组病例死亡2例，其余38例获得随访，随访6～12月，恢复工作20例，自理生活12例，需要他人照顾6例；无再出血，14例出现癫痫发作，需服药控制。结论急诊开颅清除血肿的同时尽可能摘除畸形血管是治疗该病的首选方法。     

Expression of angiogenic factors in cerebral arteriovenous malformations

BACKGROUND： In the process of vascularization, vascular endothelial growth factor （VEGF）, angiopoietin-2 and Tie2 are involved in the migration, differentiation and proliferation of vascular endothelial cells, and stimulate the rapid angiogenesis; Tiel and angiopoietin-1 play important roles in facilitating the formation of vascular lumen and maintaining the integrity of vascular wall. Thus the distributions and expressions may be associated with the occurrence of cerebral arteriovenous malformation. OBJECTIVE： To observe the biological effects of angiogenic factors in the occurrence and development of cerebral arteriovenous malformation. DESIGN： An observational comparative experiment. SETTINGS： Department of Neurosurgery, General Hospital of Shenyang Military Area Command of Chinese PLA; Department of Neurosurgery, General Hospital of Tianjin Medical University. PARTICIPANTS： Fresh samples of complete cerebral arteriovenous malformations resected in 47 patients were collected from the Department of Neurosurgery, General Hospital of Tianjin Medical University from August 1999 to May 2001, including 22 males and 25 females, the mean age was 34.5 years. Informed consents were obtained from all the patients or their relatives. The initial symptom was hemorrhage in 28 cases. All the patients were classified according to the clinical imaging data and Spetzler-Martin grading standard, including 11 cases of grade Ⅰ, 17 cases of grade Ⅱ, 11 cases of grade Ⅲ, and 8 cases of grade Ⅳ - Ⅴ. Normal brain tissues resected by decompression due to trauma were taken from 8 patients as controls, including 5 males and 3 females, aging 12 - 65 years. METHODS： ① The expressions of VEGF, Tie receptors, angiopoietin-1, angiopoietin-2, proto-oncogene c-myc and proliferating cell nuclear antigen（PCNA） in the samples of cerebral arteriovenous malformation were detected with immunohistochemical method. Under light microscope, the positively stained rat-anti-human factor Ⅷ-related antigens （specific marker of vascular endothelial cells） were counted, then the immuno-positive cells of the other antibodies in the visual field of neighboring section which was in ＂mirror＂ relation were counted, and the percentage of the latter to the former was considered as the labeling index of positive cells. The immunostaining intensity was classified negative （ - ）： no positive cells; positive （＋）： number of positive cells 〈 20%; moderately positive （＋＋）： number of positive cells 20% - 50%; strongly positive （＋＋＋）： number of positive cells 〉 50%. ② The differences of the enumeration data were compared with chi-squam test, and the correlation were analyzed with the linear correlation analysis. MAIN OUTCOME MEASURES： Expressions and distributions of VEGF, Tie 1 and Tie2 receptors, angiopoietin-1, angiopoietin-2, PCNA and c-myc in the samples of cerebral arteriovenons malformation and normal brain tissue. RESULTS： ① Expressions of angiogenic factors in the control group and cerebral arteriovenons malformation groups of each grade： The positive rates of VEGF, Tie2, angiopoietin-2, c-myc and PCNA expressions in the control group were significantly different from those in the cerebral arteriovenous malformation groups of each grade （ x^2=21.09 - 34.23, P 〈 0.05）, whereas the positive rates of Tiel and angiopoietin-1 expressions were close （ x^2=3.43 - 3.869, P 〉 0.05）. ② Expressions of angiogenic factors in hemorrhage group and non-hemorrhage group： The expressions of VEGF, angiopoietin-2 and PCNA in the hemorrhage group were significantly lower than those in the non-hemorrhage group （ x^2= 16.22 - 26.56, P 〈 0.05）. There ware no obvious differences in the expressions of Tiel and angiopoietin-1 expressions between the hemorrhage group and non-hemorrhage group （ x^2=3.22 - 3.78, P 〉 0.05）.The VEGF was positively correlated with the expressions of c-myc and PCNA （r = 0.728, 0.916, P 〈 0.05）. CONCLUSION： ①The expressions of angiogenic factors and related receptors may be involved in the process of cerebral arteriovenous malformation, and had important correlation the its clinical grading. ② Angiogenic factors may induce the expression of endothelial cell c-myc in cerebral arteriovenous malformation, and then interfere the cell proliferation and apoptosis.     

Expression of angiogenic factors in cerebral arteriovenous malformations

BACKGROUND: In the process of vascularization, vascular endothelial growth factor (VEGF), angiopoietin-2 and Tie2 are involved in the migration, differentiation and proliferation of vascular endothelial cells, and stimulate the rapid angiogenesis; Tie1 and angiopoietin-1 play important roles in facilitating the formation of vascular lumen and maintaining the integrity of vascular wall. Thus the distributions and expressions may be associated with the occurrence of cerebral arteriovenous malformation. OBJECTIVE: To observe the biological effects of angiogenic factors in the occurrence and development of cerebral arteriovenous malformation. DESIGN: An observational comparative experiment. SETTINGS: Department of Neurosurgery, General Hospital of Shenyang Military Area Command of Chinese PLA; Department of Neurosurgery, General Hospital of Tianjin Medical University. PARTICIPANTS: Fresh samples of complete cerebral arteriovenous malformations resected in 47 patients were collected from the Department of Neurosurgery, General Hospital of Tianjin Medical University from August 1999 to May 2001, including 22 males and 25 females, the mean age was 34.5 years. Informed consents were obtained from all the patients or their relatives. The initial symptom was hemorrhage in 28 cases. All the patients were classified according to the clinical imaging data and Spetzler-Martin grading standard, including 11 cases of gradeⅠ, 17 cases of grade Ⅱ, 11 cases of grade Ⅲ, and 8 cases of grade Ⅳ–Ⅴ. Normal brain tissues resected by decompression due to trauma were taken from 8 patients as controls, including 5 males and 3 females, aging 12–65 years. METHODS: ① The expressions of VEGF, Tie receptors, angiopoietin-1, angiopoietin-2, proto-oncogene c-myc and proliferating cell nuclear antigen(PCNA) in the samples of cerebral arteriovenous malformation were detected with immunohistochemical method. Under light microscope, the positively stained rat-anti-human factor VIII-related antigens (specific marker of vascular endothelial cells) were counted, then the immuno-positive cells of the other antibodies in the visual field of neighboring section which was in "mirror" relation were counted, and the percentage of the latter to the former was considered as the labeling index of positive cells. The immunostaining intensity was classified negative (–): no positive cells; positive (+): number of positive cells < 20%; moderately positive (++): number of positive cells 20%–50%; strongly positive (+++): number of positive cells > 50%. ② The differences of the enumeration data were compared with chi-square test, and the correlation were analyzed with the linear correlation analysis. MAIN OUTCOME MEASURES: Expressions and distributions of VEGF, Tie1 and Tie2 receptors, angiopoietin-1, angiopoietin-2, PCNA and c-myc in the samples of cerebral arteriovenous malformation and normal brain tissue. RESULTS: ① Expressions of angiogenic factors in the control group and cerebral arteriovenous malformation groups of each grade: The positive rates of VEGF, Tie2, angiopoietin-2, c-myc and PCNA expressions in the control group were significantly different from those in the cerebral arteriovenous malformation groups of each grade (χ2=21.09–34.23, P < 0.05), whereas the positive rates of Tie1 and angiopoietin-1 expressions were close (χ2=3.43–3.869, P > 0.05). ② Expressions of angiogenic factors in hemorrhage group and non-hemorrhage group: The expressions of VEGF, angiopoietin-2 and PCNA in the hemorrhage group were significantly lower than those in the non-hemorrhage group (χ2=16.22–26.56, P < 0.05). There ware no obvious differences in the expressions of Tie1 and angiopoietin-1 expressions between the hemorrhage group and non-hemorrhage group (χ2=3.22–3.78, P > 0.05). The VEGF was positively correlated with the expressions of c-myc and PCNA (r = 0.728, 0.916, P < 0.05). CONCLUSION: ① The expressions of angiogenic factors and related receptors may be involved in the process of cerebral arteriovenous malformation, and had important correlation the its clinical grading. ② Angiogenic factors may induce the expression of endothelial cell c-myc in cerebral arteriovenous malformation, and then interfere the cell proliferation and apoptosis.     

骨桥蛋白在人脑动静脉畸形的表达及意义

目的研究骨桥蛋白(OPN)在脑动静脉畸形(CAVM)的血管组织及其在放射、栓塞治疗后血管病理变化中的表达。方法采用免疫组化方法检测42例CAVM病理标本及对照组10例内减压手术所获脑组织血管中OPN的表达。结果26例无术前治疗史的畸形血管组织中22例有OPN的表达,主要见于CAVM的静脉部分,在粥样硬化样病变的动脉处也有表达。对照组脑组织的血管中未见OPN的表达;有伽玛刀治疗史的5例中,2例在早、中期放射反应的动脉中可见OPN的明显表达;在经历栓塞治疗的11例中,7例在新生内膜组织或异物巨细胞中有强阳性表达。结论人CAVM血管组织中多有OPN的表达,这可能是其适应于适应血流动力学状态而具有的血管重塑的表现,并可能在放射及栓塞治疗后的血管重塑中发挥重要作用。     

脑动静脉畸形的血管造影诊断与栓塞治疗

目的加深对脑动静脉畸形(AVM)数字减影血管造影(DSA)表现特点的认识,并探讨其血管内栓塞治疗价值.方法回顾性分析98例脑动静脉畸形的血管内介入诊疗资料.结果DSA均可显示供血动脉、畸形血管团和引流静脉,获得明确的诊断.98例脑AVM中病灶最大直径4.0 cm以下者57例,位于深部46例,单支供血动脉17例,深部引流16例,单支引流静脉37例(P＜0.05).52例栓塞治疗的技术成功率为100%,单纯真丝线段栓塞36例,真丝线段和NBCA联合栓塞16例.栓塞程度:畸形血管团完全消失者12例,畸形血管团减少75%以上者21例,畸形血管团减少在50%～74%之间者11例,畸形血管团缩小不足50%者8例.结论DSA检查是脑动静脉畸形可靠的诊断方法,有利于估计其预后并制订治疗方案,血管内栓塞治疗是其安全有效的治疗手段.     

儿童脑动静脉畸形的临床特点与治疗

目的总结分析儿童脑动静脉畸形（AVMs）的临床特点及治疗效果。方法回顾性分析34例儿童脑动静脉畸形患者的临床资料。结果本组病例平均年龄10．4岁,其中21例表现脑出血;按Spetzler—Martin分级,Ⅰ级8例,Ⅱ级13例,Ⅲ级9例,Ⅳ级4例;随访30例中,疗效优22例,良5例,差1例,死亡2例。结论儿童脑AVM最常见的临床表现是脑出血,综合治疗能获得良好临床效果。     

脑动静脉畸形术中的多普勒超声应用研究

本文报道手术中应用两种不同型号的多普勒超声仪经脑皮层检测脑动静畸形（ＡＶＭ）１７例，仅１例住于皮层下３．５ｃｍ的ＡＶＭ以１０ＭＨｚ多普勒超声检测未显示病灶信号。ＡＶＭ供血动脉通端流速比近端快，脉动指数（ＰＩ）更降低，畸形血管因血流更紊乱，其流速低于邻近供血动脉、其ＰＩ比供血动脉远近端均低。多普勒超声应用于ＡＶＭ术中能提供ＡＶＭ精确定位资料，区分ＡＶＭ供血动脉和脑营养动脉，ＡＶＭ引流静脉和脑正常静脉，并检验ＡＶＭ切除是否彻底。     

Stereotactic radiosurgery for deep intracranial arteriovenous malformations,part 1: Brainstem arteriovenous malformations

The management of brainstem arteriovenous malformations (AVM) are one of the greatest challenges encountered by neurosurgeons. Brainstem AVM have a higher risk of hemorrhage compared to AVM in other locations, and rupture of these lesions commonly results in devastating neurological morbidity and mortality. The potential morbidity associated with currently available treatment modalities further compounds the complexity of decision making for affected patients. Stereotactic radiosurgery (SRS) has an important role in the management of brainstem AVM. SRS offers acceptable obliteration rates with lower risks of hemorrhage occurring during the latency period. Complex nidal architecture requires a multi-disciplinary treatment approach. Nidi partly involving subpial/epipial regions of the dorsal midbrain or cerebellopontine angle should be considered for a combination of endovascular embolization, micro-surgical resection and SRS. Considering the fact that incompletely obliterated lesions (even when reduced in size) could still cause lethal hemorrhages, additional treatment, including repeat SRS and surgical resection should be considered when complete obliteration is not achieved by first SRS. Patients with brainstem AVM require continued clinical and radiological observation and follow-up after SRS, well after angiographic obliteration has been confirmed.     

Diagnostic value of electroencephalography in arteriovenous malformations

Arteriovenous malformations (AVM) are usually located superficially in the subcortical white matter, and seizures are one of the frequently seen presenting features of AVM. The diagnosis of AVM is confirmed with various neuroimaging techniques. The present study comprised six patients presenting with seizures and headaches, referred to the neurodiagnostic unit to rule out/confirm epilepsy. All patients showed epileptiform activity on electroencephalography (EEG). Further investigations, such as angiography supplemented with computed tomography (CT) showed AVM. EEG is usually not considered a valuable diagnostic tool in AVM, but our results support the finding that EEG is an extremely reliable investigative tool, and should be supplemented with angiography and CT scan for better localization of AVM.     

Spinal vascular malformations in non-perimesencephalic subarachnoid hemorrhage

Objective   In patients with non-traumatic subarachnoid hemorrhage (SAH) and no evidence for a cerebral aneurysm on angiography, a frequent cause of the hemorrhage is perimesencephalic hemorrhage or other cerebral vascular pathology. In some patients no cause is found. The exact incidence of a spinal vascular malformation (SVM) as the origin for the SAH is not known. We assessed the occurrence of SVM in angiogram-negative, non-perimesencephalic subarachnoid hemorrhage (NPSAH). Methods   47 patients (from a consecutive cohort of 632) were identified with an angiogramnegative, non-perimesencephalic subarachnoid hemorrhage and 42 of these were analyzed by performing MR-imaging of the complete spinal neuraxis with additional spinal angiography on indication. Results   In four patients a spinal vascular malformation was identified as the cause of the SAH, indicating an incidence of 9 % of SVM in NPSAH, and an incidence of 1 % of SVM in all patients with SAH. Interpretation   Systematic analysis of angiogram-negative, non-perimesencephalic subarachnoid hemorrhage by MR imaging of the complete spinal neuraxis yields a higher incidence of SVM than previously documented. We recommend MR imaging of the complete spinal neuraxis in patients with a non-perimesencephalic subarachnoid hemorrhage in whom no cause for the hemorrhage has been found.     

以出血为首发症状的脑动静脉畸形的自然史

目的 初步研究以出血为首发症状的脑动静脉畸形的自然史.方法 通过采集782例脑动静脉畸形病例的病史资料,并对其中104例未接受任何手术或放射治疗的以出血为首发症状的AVM病例随访,然后对病史资料及随访资料进行统计和分析.结果 诊断后的3年死亡率为7.5%.影响再出血的危险因素为AVM位置,位于深部者更易再出血.就诊后第一年再出血率为10%,3年再出血率为19.6%.再出血死亡率为13.3%.随访患者无1例有后期癫(癎)发作.出血后不伴有神经功能障碍的患者无1例后期致残.结论 首发症状为出血的AVM再出血的危险性与AVM位置有关.由出血导致的癫(癎)发作及神经功能障碍预后较好.     

Onyx在颅内动静脉畸形栓塞治疗中的初步应用

目的总结Onyx在颅内动静脉畸形(AVM)栓塞治疗中的初步临床应用。方法应用Onyx对10例DSA确诊的颅内AVM进行栓塞治疗。AVM的直径在3~8cm,其中直径大于6cm的大型AVM6例。选用Ultraflow或Marathon微导管。每支供血动脉的注胶时间10~45min。结果栓塞结束时复查血管造影,畸形血管团闭塞30%~50%1例,50%~80%2例,80%~90%4例,90%以上3例。术毕1例患者将微导管留置体内。全部病例随访2~12月无再出血。结论应用Onyx栓塞AVM可以较长时间的注胶,娴熟掌握注胶技巧和控制返流能够提高AVM的栓塞疗效。     

Nongalenic cerebral arteriovenous malformations in neonates and infants Review of 26 consecutive cases (1982–1992)

We present 26 consecutive cases of nongalenic pial arteriovenous malformations (PAVMs) diagnosed in the neonatal period or in infancy. No diagnosis was made antenatally. Presenting symptoms in neonates were systemic cardiac manifestations (54%), seizures (31%), and hemorrhages (15%). In infants, hemorrhagic strokes and hydrodynamic disorders (external or internal hydrocephaly, macrocephaly, atrophy) both occurred in 38% of cases. Systemic cardiac manifestations and seizures were rare at that age (respectively 16% and 8%). Sixty-two percent of neonates and 31% of infants already had neurocognitive disorders (assessed by pediatric neurocognitive testing: Brunet-Leizine and Denver tests) when referred. The venous drainage and its anomalies (ectasias, stenoses, thromboses) were the main causes of symptoms. Atrophy and leukomalacic lesions occurred rapidly; they express local hydrovenous disorders and are specific to this population group. Untreated neonates and infants have a poor prognosis. Endovascular treatment, although partial and challenging in all instances, represents the treatment of choice in our series. Of the eight neonates treated, one improved to normal (12.5%), while four remained stable (50%): two neurologically normal, two with mild neurological deficit. Three (37%) died despite embolization (heart failure, multiorgan failure, postoperative death). Transient neurological complications occurred in two cases (25%): hemiparesis in one patient with a rolandic and in one with a thalamic AVM. Of the eight infants successfully embolized, one was significantly improved (12.5%) and is now neurologically normal, while five remained stable (62.5%): four neurologically normal, one with mild neurological deficit. One died between two sessions of embolization from intracerebral hemorrhage (12.5%). Hemianopsy occurred in one case (12.5%) after embolization of an occipital AVM. In one additional case in a normal child we failed to embolize the last small pial AVM of four after the three others had spontaneously thrombosed. With a minimal follow-up of 18 months and a maximum of 7 years, the review of our series shows 53% of the initial group of neonates and infants growing neurologically normal after therapeutic management in our institution; 23.5% died despite treatment, and the remaining 23.5% present minor neurological deficit. When targeted at the points of angioarchitectural weakness, embolization contributes to stabilizing a lesion. It should be undertaken rapidly to avoid loss of brain substance secondary to hemorrhage, atrophy, or leukomalacia, and to allow neurocognitive recovery and normal brain maturation. In our experience, theses lesions are the most aggressive ones for the maturating brain, and the most difficult to approach technically. They represent a new therapeutic field and have their own specific anatomy and physiology.     

Fractionated, stereotactic proton beam treatment of cerebral arteriovenous malformations

OBJECTIVES: To evaluate the therapeutic efficiency and adverse effects of stereotactic proton beam treatment of cerebral arteriovenous malformations (AVM). MATERIAL AND METHODS: Twenty-six patients treated in Uppsala during 1991-97 were included (men = 14, women = 12; mean age = 39, range = 23-64). The nidus volumes ranged from 0.3 to 102 ml (mean = 24, median = 13). The follow-up included clinical evaluation, magnetic resonance imaging (and/or computed tomography) every 6-12 months for 3 years and final angiography. RESULTS: The volume changes at final follow-up in AVMs >25 ml were -89, -85, -44, -29, -7, 0, 0, +5 and +18 (%); in AVMs 11-24 ml, -100, -100, -97, -92 and 0 (%); and in AVMs <10 ml, -100, -100, -100, -100, -100, -99, -98, -50, -0 and +40 (%). Two patients were lost to follow-up due to cerebral haemorrhage and myocardial infarction. Radiology displayed significant perifocal oedema in one patient and slight oedema in four patients. Of nine patients with epilepsy, seven became seizure-free after therapy while two continued to suffer from seizures. CONCLUSION: Proton beam irradiation is successful in a relatively high proportion of intermediate and large-sized cerebral AVMs. The adverse effects are acceptable. The advantage of proton treatment compared with gamma knife and LINAC stereotactic irradiation is that protons can irradiate even large volumes with a very sharp dose profile against normal surroundings. Thus, proton beam irradiation is a valuable option in the treatment of AVMs larger than 10 ml.     

Onyx胶栓塞颅内动静脉畸形的临床分析

目的 探讨Onyx胶栓塞颅内动静脉畸形的临床效果。方法 回顾性分析2008年1月至2014年12月采用Onyx胶栓塞治疗的120例颅内动静脉畸形患者的临床资料。结果 栓塞范围≥80% 56例（畸形团完全闭塞14例）,<80% 64例。术中少量出血2例,术后无神经功能缺损。术后出血4例,其中2例死亡。术后一过性神经功能缺损2例。118例随访2~48个月,平均（25.1±5.6）个月,患者头痛、头晕及癫痫等均得到不同程度改善;其中45例DSA随访示,完全闭塞26例,与术前比较无变化19例。结论 Onyx胶血管内栓塞治疗脑动静脉畸形具有良好的效果,但是应掌握其适应症和使用方法。     

Stereotactic radiosurgery for deep intracranial arteriovenous malformations,part 2: Basal ganglia and thalamus arteriovenous malformations

The aim of this review is to critically analyze the outcomes following stereotactic radiosurgery (SRS) for arteriovenous malformations (AVM) of the basal ganglia and thalamus. The management of these deep-seated lesions continues to challenge neurosurgeons. Basal ganglia and thalamic AVM show a higher risk of hemorrhage, and an associated devastating morbidity and mortality, as compared to AVM in more superficial locations. Any of the currently available treatment modalities may fail or result in iatrogenic neurologic deterioration. Recent evidence from A Randomized Trial of Unruptured Brain AVM (ARUBA) further deters aggressive approaches that carry a significant risk of treatment-related adverse events. Microsurgical resection, endovascular embolization and SRS all play a role in the treatment of AVM. SRS is an effective therapeutic option for AVM of the thalamus and basal ganglia that are deemed high risk for resection. SRS offers acceptable obliteration rates, with generally lower risks of hemorrhage occurring during the latency period compared to the AVM natural history. Considering that incompletely obliterated lesions still harbor the potential for rupture, additional treatments such as repeat SRS and microsurgical resection should be considered when complete obliteration is not achieved by an initial SRS procedure. Patients with AVM of the basal ganglia and thalamus require continued clinical and radiologic observation and follow-up after SRS, even after angiographic obliteration has been confirmed.     

Stereotactic clipping of arteriovenous malformations of the brain

The authors have developed a new technique for the stereotactic clipping of the feeding vessels of deep-seated arteriovenous malformations (AVM), for use when direct attack may be very dangerous or impossible. A special clipping device and the technique for its application are described. The instrument is introduced through a burr hole using the stereotactic apparatus designed by the authors. The clipping is monitored by intraoperative angiography. The method was used in 32 patients with supratentorial AVMs. It is concluded that in selected cases the method is effective, is less traumatic and gives successful results.     

Volume-staged stereotactic radiosurgery for large intracranial arteriovenous malformations

Stereotactic radiosurgery (SRS) is an effective treatment option for intracranial arteriovenous malformations (AVM). However, the treatment of large AVMs (nidus volume ≥12 cm³) with single-session SRS alone yields generally poor outcomes. Volume-staged SRS (VS-SRS) is a therapeutic strategy for large AVMs which seeks to avoid the disadvantages of single-session SRS, but reports regarding its efficacy remain limited. The aim of this retrospective cohort study is to assess the outcomes of VS-SRS for large AVMs. We identified all AVM patients who underwent VS-SRS at our institution from 2000 to 2015 with ≥12 months follow-up. Baseline and outcomes data were analyzed. A total of 12 patients were selected for the study cohort, with a median age of 30 years. The median maximum AVM diameter and nidus volume were 4.3 cm and 13.6 cm³, respectively. The Spetzler–Martin grade was III and IV each in six AVMs (50%). All patients underwent VS-SRS in two stages, and the median margin dose was 17 Gy for both VS-SRS procedures. The median time interval between the two procedures was three months. After a median radiologic follow-up duration of 39 months, the median degree of AVM volume reduction (evaluable in nine patients) was 87% (range 12–99%). The rates of radiologically evident, symptomatic, and permanent radiation-induced changes were 58%, 25%, and 8%, respectively. There were no cases of post-SRS hemorrhage. VS-SRS substantially reduces the size of large AVMs. A potential role for VS-SRS may be to facilitate subsequent definitive intervention to obliterate a shrunken, residual nidus.