Gamma knife radiosurgery for symptomatic brainstem intra-axial cavernous malformations

Long-Term Outcomes of Gamma Knife Radiosurgery for Cerebral Cavernous Malformations: 10 Years and Beyond

BACKGROUND

We aimed to evaluate long-term outcomes of gamma knife radiosurgery (GKS) for cerebral cavernous malformations (CCMs).

METHODS

Among the 233 CCM patients who underwent GKS, 79 adult patients (96 lesions) followed for over 10 years were included and analyzed retrospectively. Annual hemorrhage rate (AHR) was analyzed the entire cohort of 233 patients and the subset of 79 enrolled patients by dividing lesions into overall CCM lesions and brainstem lesions. AHR, neurologic outcome, adverse radiation effect (ARE), and changes of lesions in magnetic resonance imaging (MRI) were compared before and after GKS. Cox-regression analysis was performed to identify risk factors for hemorrhage following GKS.

RESULTS

Mean follow-up duration of 79 enrolled patients was 14 years (range, 10-23 years). The AHR of all CCMs for entire cohort at each time point was 17.8% (pre-GKS), 5.9% (≤ 2 years post-GKS), 1.8% (≤ 10 years post-GKS). The AHR of all CCM for 79 enrolled patients was 21.4% (pre-GKS), 3.8% (2 years post-GKS), 1.4% (10 years post-GKS), and 2.3% (> 10 years post-GKS). The AHR of brainstem cavernous malformation (CM) for entire cohort at each time point was 22.4% (pre-GKS), 10.1% (≤ 2 years post-GKS), 3.2% (≤ 10 years post-GKS). The AHR of brainstem CM for 79 enrolled patients was 27.2% (pre-GKS), 5.8% (2 years post-GKS), 3.4% (10 years post-GKS), and 3.5% (> 10 years post-GKS). Out of the 79 enrolled patients, 35 presented with focal neurologic deficits at the initial clinical visit. Among these patients, 74.3% showed recovery at the last follow-up. Symptomatic ARE occurred in five (6.4%) patients. No mortality occurred. Most lesions were decreased in size at the last follow-up MRI. Previous hemorrhage history (hazard ratio [HR], 8.38; 95% confidence interval [CI], 1.07-65.88; P = 0.043), and brainstem location (HR, 3.10; 95% CI, 1.26-7.64; P = 0.014) were significant risk factors for hemorrhage event.

CONCLUSION

GKS for CCM showed favorable long-term outcomes. GKS should be considered for CCM, especially when it has a previous hemorrhage history and brainstem location.

Stereotactic radiosurgery for intracranial cavernous malformations of the deep-seated locations: systematic review and meta-analysis

OBJECTIVE

To determine the outcomes of stereotactic radiosurgery (SRS) for deep-seated (brainstem, basal ganglia, thalamus, cerebellar peduncle) intracranial cavernous malformations (ICMs).

METHODS

A systematic review and meta-analysis was performed according to PRISMA and MOOSE guidelines. The main outcomes were comparing pre- and post-SRS hemorrhage rates, using the pooled risk ratios (RR) as the measure of effect. Additionally, the study assessed lesion volume changes and radiation-injury incidence.

RESULTS

Data of 850 patients across 14 studies were included in the meta-analysis. The pooled RR of all deep-seated ICMs show a decrease in hemorrhage rate after SRS compared to pre-SRS over the total follow-up period (RR =0.13), initial 2 years (RR =0.22), and after 2 years (RR =0.07). For 9 studies that reported hemorrhage rate of the brainstem only, the pooled RR shows a decrease of hemorrhage rate after SRS compared to pre-SRS over the total follow-up period (RR =0.13), initial 2 years (RR =0.19), and after 2 years (RR =0.07). Volumetric regression was achieved in 44.25% and stability in 56.1%. The pooled incidence of symptomatic and permanent radiation injury was 9% (95% CI, 7-11) and 3% (95% CI, 0-1.9%), respectively.

CONCLUSION

SRS appears effective in reducing hemorrhage rates for deep-seated ICMs. The risk of symptomatic radiation injury is low. Given the high risk of surgical morbidity, SRS is a reasonable treatment option for patients with deep-seated ICMs with at least one prior hemorrhage.

Brainstem Cavernous Malformations Management: Microsurgery vs. Radiosurgery, a Meta-Analysis

Given the rareness of available data, we performed a systematic review and meta-analysis on therapeutic strategy microsurgical resection and stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs) and assessed mortality, permanent neurological deficits (PNDs), rebleeding rate, and patients who require reintervention to elucidate the benefits of each treatment modality. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were used for protocol development and manuscript preparation. After applying all inclusion and exclusion criteria, six remaining articles were included in the final manuscript pool. In total, this meta-analysis included 396 patients, among them 168 patients underwent microsurgical treatment and 228 underwent SRS. Findings of the present meta-analysis suggest that regarding the total group of patients, in terms of mortality, late rebleeding rate, and PNDs, there was no superiority of the one method over the other. Applying the leave-one-out method to our study suggests that with low robust of the results for the bleeding rate and patients who require reintervention outcome factor, there was no statistical difference among the surgical and SRS treatment. Microsurgical treatment of BSCMs immediately eliminates the risk of rehemorrhage; however, it requires complete excision of the lesion and it is associated with a similar rate of PNDs compared with SRS management. Apparently, SRS of BSCMs causes a marked reduction in the risk of rebleeding 2 years after treatment, but when compared with the surgical treatment, there was not any remarkable difference.

Microsurgery vs. Gamma Knife Radiosurgery for the Treatment of Brainstem Cavernous Malformations: A Systematic Review and Meta-Analysis

Background: Brainstem cavernous malformations (BSCMs) are a subset of cerebral cavernous malformations with precarious locations and potentially devastating clinical courses. The effects and outcomes of treating BSCMs by microsurgery or gamma knife radiosurgery (GKRS) vary across studies.

Methods: We searched the Medline, Web of Science, The Cochrane Library, PubMed, and China Biology Medicine disc databases for original articles published in peer-reviewed journals of cohort studies reporting on 20 or more patients of any age with BSCMs with at least 80% completeness of follow-up.

Results: We included 43 cohorts involving 2,492 patients. Both microsurgery (RR = 0.04, 95% CI 0.01–0.16, P < 0.01) and GKRS (RR = 0.11, 95% CI 0.08–0.16, P < 0.01) demonstrated great efficacy in reducing the rehemorrhage rate after treatment for BSCMs. The incidence rates of composite outcomes were 19.8 (95% CI 16.8–22.8) and 15.7 (95% CI 11.7–19.6) after neurosurgery and radiosurgery, respectively. In addition, we found statistically significant differences in the median numbers of patients between neurosurgical and radiosurgical cohorts in terms of symptomatic intracranial hemorrhage (ICH; neurosurgical cohorts: median 0, range 0–33; radiosurgical cohorts: median 4, range 1–14; P < 0.05) and persistent focal neurological deficit (FND; neurosurgical cohorts: median 5, range 0–140; radiosurgical cohorts: median 1, range 0–3; P < 0.05).

Conclusions: The reported effects of treating BSCMs by microsurgery or GKRS are favorable for reducing recurrent hemorrhage from BSCMs. Patients in the neurosurgery cohort had a lower incidence of symptomatic ICH, while patients in the radiosurgical cohort had a lower incidence of persistent FND.

Stereotactic radiosurgery for cerebral cavernous malformations: A systematic review

OBJECTIVE

The efficacy of stereotactic radiosurgery (SRS) for the treatment of cerebral cavernous malformations (CCMs) is uncertain, so we set out to quantify clinical outcomes after SRS for CCM and compare them to microsurgical excision or conservative management.

METHODS

We searched Ovid Medline and Ovid EMBASE from inception until June 1, 2018, for peer-reviewed publications describing clinical outcomes after SRS for ≥10 people with CCM in cohorts with or without a comparison group treated with neurosurgical excision or conservative management. Two reviewers independently extracted data from the included studies to quantify cohort characteristics and the incidence of the primary outcome (death attributable to CCM or its treatment) and secondary outcomes (incident nonfatal symptomatic intracerebral hemorrhage [ICH] and incident nonhemorrhagic persistent focal neurologic deficit [FND]). We assessed whether comparative studies showed a dramatic association (meaning the conventionally calculated probability comparing 2 differently managed patient groups from the same population was <0.01 with a rate ratio greater than 10).

RESULTS

We included 30 cohort studies involving a total of 1,576 patients undergoing SRS for CCM. Four nonrandomized studies compared SRS to other treatment strategies, but did not demonstrate dramatic associations. During a median follow-up of 48 (interquartile range 35-62) months after SRS, the annual incidences (95% confidence interval) of outcomes were death 0.18% (0.10-0.31), ICH 2.40% (2.05-2.80), FND 0.71% (0.53-0.96), and the composite of death, ICH, or FND 3.63% (3.17-4.16). Outcomes did not differ by CCM location or type of SRS.

CONCLUSION

After SRS for CCM, the annual incidences of death, ICH, and FND are <5% and seem comparable to outcomes without SRS. A randomized trial of SRS for CCM is needed.

Stereotactic Radiosurgery for Brainstem Cavernous Malformations: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

This study was conducted to achieve more conclusive evidence for the efficacy of stereotactic radiosurgery (SRS) for brainstem cavernous malformations (BSCMs).

METHODS

A literature search of PubMed, EMBASE, and Web of Science was performed and studies reporting the outcomes of SRS for BSCMs were included. The primary outcome was the pre-SRS and post-SRS hemorrhage rates; the pooled incidence rate ratio (IRR) with 95% confidence interval was chosen as effect size. Lesion control, symptom change, and radiation-related complications were evaluated.

RESULTS

A total of 576 patients across 14 studies were included in this meta-analysis. The post-SRS hemorrhage rate was significantly decreased compared with the pre-SRS rate (IRR, 0.123; P < 0.001), and the hemorrhage rate 2 years after SRS was significantly lower than that within 2 years after SRS (IRR, 0.317; P < 0.001). Ten among 14 studies have shown that the symptoms were improved or stationary after SRS. Lesion volume was reduced in 47.3% of the patients and was stationary in 49.4% on the last follow-up images. Symptomatic adverse radiation effects (AREs) developed in 7.3% and permanent AREs were observed in 2.2%. In subgroup analysis, studies having mean marginal dose of ≤13 Gy showed statistically significantly lower development of symptomatic AREs than those having mean marginal dose of >13Gy (2.0% vs. 10.8%; P = 0.008).

CONCLUSIONS

SRS using a relatively low marginal dose can be a safe and effective treatment for BSCM. Further prospective studies are necessary to confirm the optimal radiation dose and efficacy of SRS for BSCMs.

Gamma Knife Radiosurgery for Trigeminal Neuralgia Caused by a Cavernous Malformation: Case Report and Literature Review

OBJECTIVE

Trigeminal neuralgia (TN) related to a brainstem cavernous malformation (CM) is a rare entity. We present the first radiosurgical management of a patient with TN secondary to a CM.

CLINICAL PRESENTATION

An 80-year-old female presented with a 33-year history of progressively severe TN refractory to medications. Imaging confirmed a solitary CM located at the pontine dorsal root entry zone of cranial nerve 5.

TREATMENT

Stereotactic radiosurgery of the trigeminal nerve was performed using the Leksell gamma knife. A single 4-mm isocenter of radiation was focused on the trigeminal nerve and a maximum dose of 80 Gy (40 Gy at the 50% isodose line) was delivered to the nerve.

RESULTS

At 1 year, the patient noted that the severe pain attacks had been reduced by 75%, although a background lingering discomfort persisted. Pain suppression medications had been significantly reduced to lamotrigine 100 mg twice daily. Her preoperative distribution of sensory dysfunction mildly increased.

CONCLUSION

For medically refractory TN related to a CM, radiosurgery of the afferent nerve may ameliorate pain without a major decrease in sensation. The more than 30-year history of pain in our patient may have reduced the chance of more significant pain relief.

The Efficacy of Gamma Knife Radiosurgery for Cavernous Malformations: A Meta-Analysis and Review

OBJECTIVE

This meta-analysis is to evaluate the clinical efficacy of gamma knife radiosurgery (GKRS) for treating cavernous malformations.

METHODS

PubMed, Ovid Embase, and Ovid Medline electronic databases were searched. The primary outcome is hemorrhage rate and this meta-analysis is performed.

RESULTS

Nine studies are included in this meta-analysis. The overall risk ratio (RR) of hemorrhage rate of pre-GKRS and post-GKRS is 6.08 (95% confidence interval [CI], 5.04-7.35). The overall RR is 3.03 (95% CI, 2.65-4.11) between the hemorrhage rate of pre-GKRS and the first 2 years postradiosurgery, and the overall RR is 12.13 (95% CI, 1.73-85.07) comparing pre-GKRS with 2 years after GKRS. There is no significant difference of the hemorrhage rate between the first 2 years postradiosurgery and 2 years after GKRS (RR = 2.81; 95% CI, 0.20-13.42). The neurologic deficiency is the most common radiosurgery-related complication.

CONCLUSIONS

Patients with cerebral cavernous malformations, especially ones that were deep seated and surgically inaccessible, seem to benefit from GKRS owing to a reduction of annual hemorrhage rate in the first 2 years and 2 years after, despite several cases that suffer from negative side effects of radiation.

Defining Long-Term Clinical Outcomes and Risks of Stereotactic Radiosurgery for Brainstem Cavernous Malformations

BACKGROUND

We evaluated clinical outcomes in patients with symptomatic brainstem cavernous malformations (CMs) treated by stereotactic radiosurgery (SRS).

METHODS

Between 1988 and 2016, Gamma Knife SRS was performed in 76 evaluable patients with solitary symptomatic brainstem CMs. Forty-nine (66%) were intrinsic (not reaching a pial or ependymal surface). Most patients (91%) had experienced 2 or more hemorrhages associated with new neurologic deficits. Fourteen patients (18%) underwent resection before radiosurgery. The median CM volume was 0.66 cm3 (range, 0.05-6.8), and the median margin dose was 15.0 Gy.

RESULTS

After SRS, 15 patients (20%) had an imaging confirmed new hemorrhage at a median follow-up of 48 months. The hemorrhage-free survival after SRS for brainstem CMs was 92% at 1 year, 87% at 3 years, and 85% at 5 years. The annual hemorrhage rate was 31% before and 4% after SRS. In univariate analysis, CM volume, previous surgical resection, and increased number of hemorrhages before SRS were significantly associated with a higher rate of hemorrhage after SRS. In multivariate analysis, only number of previous hemorrhages was significant (P < 0.0005; hazard ratio, 1.51, 95% confidence interval, 1.23-1.85). Symptomatic adverse radiation effects developed in 7 patients (9%). The rate of symptom deterioration related to hemorrhage or symptomatic adverse radiation effects was 10% at 1 year, 18% at 3 years, and 20% at 5 years.

CONCLUSIONS

Patients with an increased rate of hemorrhage before SRS had an increased risk of repeat hemorrhage and symptom deterioration rate after SRS. Intrinsic CM location did not significantly affect rates of symptom deterioration or rebleeding.

Brain Stem Cavernous Malformations: Operative Nuances of a Less-Invasive Resection Technique

BACKGROUND

Different operative techniques are reported for the resection of brainstem cavernous malformations (BSCMs). The senior author has previously reported on a less-invasive technique of entering the brain stem with piecemeal removal of BSCMs, especially the deep-seated ones.

OBJECTIVE

To present a larger series of these lesions, emphasizing the approach to the brain stem via case selection. We discuss the nuances of the less-invasive operative technique through case illustrations and intraoperative videos.

METHODS

A retrospective review of 46 consecutive cases of BSCMs, with their clinical and radiographic data, was performed. Nine cases were selected to illustrate 7 different operative approaches, and discuss surgical nuances of the less-invasive technique unique to each.

RESULTS

Postoperative morbidity, defined as an increase in modified Rankin Scale, was observed in 5 patients (10.9%). A residual BSCM was present in 2 patients (4.3%); both underwent reoperation to remove the remainder. At follow-up of 31.1 ± 27.8 mo, 3 patients experienced recurrence (6.5%). Overall, 65% of our patients improved, 20% stayed the same, and 11% worsened postsurgery. Two patients died, yielding a mortality of 4.3%.

CONCLUSION

Using the less-invasive resection technique for piecemeal BSCM removal, in appropriately selected patients, has yielded comparable to improved patient outcomes over existing large series. In our experience, lateral, anterolateral, and posterolateral approaches are favorable over direct midline (dorsal or ventral) approaches. A thorough understanding of brain-stem safe-entry zones, in conjunction with appropriate approach selection, is key to a good outcome in challenging cases.

Long-Term Outcome of Gamma Knife Radiosurgery for Symptomatic Brainstem Cavernous Malformation

OBJECTIVE

We sought to analyze the long-term outcome of Gamma Knife radiosurgery (GKS) for symptomatic brainstem cavernous malformation (s-BSCM).

METHODS

Forty-five patients (14 males, 31 females) were treated with GKS for s-BSCM from January 1998 to December 2011. All patients were followed up for >5 years, and their clinical data were analyzed retrospectively. All patients had a history of symptomatic bleeding once or more before GKS. These hemorrhages caused neurologic deficits including cranial nerve deficits, hemiparesis, hemisensory deficits, spasticity, or chorea. The mean target volume of s-BSCM was 1.82 cm³, and the median prescribed marginal dose of radiation was 13 Gy. The mean clinical and imaging follow-up period was 9.31 years (range 5.1-19.4 years).

RESULTS

The 45 patients had 69 hemorrhagic events before GKS. During the follow-up period after GKS, 35 patients had no hemorrhagic event, 6 patients had 1 episode of symptomatic hemorrhage, and 4 patients had 2 episodes. The calculated annual hemorrhage rate was 40.06% at pre-GKS, 3.3% at 2 years after GKS, 1.48% at 5 years after GKS, and 4.64% at >5 years after GKS. In this study of 45 patients, symptomatic radiation-induced complications developed in only 1 patient (2.2%). No patients had died at the last follow-up.

CONCLUSIONS

GKS for s-BSCM is a safe and effective alternative to surgical resection for reducing the rate of recurrent hemorrhage. Because the annual hemorrhage rate increases >5 years after GKS, clinicians should monitor patients closely to determine their subsequent treatment.

Gamma Knife Radiosurgery of Brainstem Cavernous Malformations

BACKGROUND/AIMS

Our study aimed to evaluate the efficiency and morbidity of Gamma Knife radiosurgery (GKS) in the treatment of hemorrhagic brainstem cavernous malformations (CMs).

METHODS

We included in this study all patients who underwent GKS for the treatment of a hemorrhagic brainstem CM(s) in our institution between January 2007 and December 2012. The GKS was privileged when the surgical procedure was evaluated as very risky. The mean dose of radiation was 14.8 Gy, and the mean target volume was 0.282 cm3. All patients participated in a scheduled clinical follow-up. The posttreatment MRI was performed after 6 months and after 1 year, and then all patients had an annual MRI follow-up.

RESULTS

There were 19 patients with a mean age of 36.7 years. The mean follow-up period was 51.2 months. The annual hemorrhage rate (AHR) was 27.31% before GKS, 2.46% during the first 2 years following the GKS, and 2.46% after the first 2 years following the GKS. The decrease in AHR after GKS was significant (p < 0.001).

CONCLUSION

GKS should be suggested when the surgical procedure harbors a high risk of neurological morbidity in patients with brainstem CM. Compared to prior literature results, a lower dose than applied in this study could be discussed.

Gamma knife radiosurgery for brainstem cavernous malformations

OBJECTIVE

The goal of this retrospective study was to evaluate the efficacy and safety of gamma knife radiosurgery (GKS) for the treatment of brainstem cavernous malformations (CMs).

METHODS

Between January of 2009 and December of 2014, 43 patients (20 males and 23 females) with brainstem CMs were treated at the West China Hospital, Sichuan University, Gamma Knife Center. The mean age of these patients was 41.7 years. All of the patients experienced 1 or more episodes of symptomatic bleeding (range 1-4) before undergoing GKS. The mean volume of the malformations at the time of GKS was 442.1mm³, and the mean prescribed marginal radiation dose was 11.9Gy. The mean follow-up period after radiosurgery was 36 months (range 12-120 months).

RESULTS

Before GKS, 50 hemorrhages (1.2 per patient) were observed (25.0% annual hemorrhage rate). Three hemorrhages following GKS were observed within the first 2 years (3.92% annual hemorrhage rate), and 1 hemorrhage was observed in the period after the first 2 years (1.85% annual hemorrhage rate). In this study of 43 patients, new neurological deficits developed in only 1 patient (2.32%; permanent paresthesia on the left side of the face and the right lower limb of the patient). There were no deaths in this study.

CONCLUSION

GKS is a favorable alternative treatment for brainstem CMs. Using a low marginal dose treatment might reduce the rate of hemorrhage and radiation-induced complications.

Management of cerebral cavernous malformations: from diagnosis to treatment

Cerebral cavernous malformations are the most common vascular malformations and can be found in many locations in the brain. If left untreated, cavernomas may lead to intracerebral hemorrhage, seizures, focal neurological deficits, or headaches. As they are angiographically occult, their diagnosis relies on various MR imaging techniques, which detect different characteristics of the lesions as well as aiding in planning the surgical treatment. The clinical presentation and the location of the lesion are the most important factors involved in determining the optimal course of treatment of cavernomas. We concisely review the literature and discuss the advantages and limitations of each of the three available methods of treatment—microsurgical resection, stereotactic radiosurgery, and conservative management—depending on the lesion characteristics.

Gamma Knife radiosurgery for brainstem cavernous malformations: should a patient wait for the rebleed?

BACKGROUND

The effectiveness of stereotactic radiosurgery (SRS) for cavernous malformation (CM) has not been fully assessed. Consequently, observation is usually recommended when a bleeding CM is initially discovered. Recurrent bleeding occurs with CMs, and these repeat hemorrhages can result in additional morbidity.

METHODS

From 1992 to 2011, 49 patients with brainstem CMs were treated with Gamma Knife radiosurgery (GKS). We classified patients into two groups: Group A (n = 31), patients who underwent GKS for a CM following a single symptomatic bleed, and group B (n = 18), patients who underwent GKS for a CM following two or more symptomatic bleeds. The mean marginal dose of radiation was 13.1 Gy (range 9.0-16.8 Gy): 12.8 Gy in group A and 13.7 Gy in group B. The mean follow-up period was 64.0 months (range 1-171 months).

RESULTS

In group A, the annual hemorrhage rate (AHR) following GKS was 7.06 % within the first 2 years and 2.03 % after 2 years. In group B, four patients (22.2 %) developed new or worsening neurologic deterioration as a result of repeat hemorrhages. In group B, the AHR was 38.36 % prior to GKS, 9.84 % within the first two years, and 1.50 % after two years. There was no statistically significant difference in the AHRs at each follow-up period after GKS between the two groups. Adverse radiation effects (AREs) developed in a total of four patients (8.2 %); among them, one patient (2.0 %) developed a permanent case of diplopia. No mortality occurred in this series.

CONCLUSION

In this study, GKS was demonstrated to be a safe and effective alternative treatment for brain stem CMs that resulted in a reduction in the AHR. Consequently, we suggest that even CM patients who have suffered only a single bleed should not be contraindicated for SRS.

Stereotactic radiosurgery of brainstem cavernous malformations: a systematic review and meta-analysis

OBJECT

Over the last two decades, stereotactic radiosurgery (SRS) has arisen as a promising approach in the management of brainstem cavernous malformations (CMs). In the present study, the authors report a systematic review and meta-analysis of the available published data regarding the radiosurgical management of brainstem CMs.

METHODS

To identify eligible studies, systematic searches for brainstem CMs treated with SRS were conducted in major scientific publication databases. The search yielded 5 studies, which were included in the meta-analysis. Data from 178 patients with brainstem CMs were extracted. Hemorrhage rates before and after SRS were calculated, a meta-analysis was performed, and the risk ratio (RR) was determined.

RESULTS

Four studies showed a statically significant reduction in the annual hemorrhage rate after SRS. The overall RR was 0.161 (95% CI 0.052-0.493; p = 0.001), and 21 patients (11.8%) had transient or permanent neurological deficits.

CONCLUSIONS

The present meta-analysis for the radiosurgical management of brainstem CMs shows that SRS can decrease the rate of repeat hemorrhage and has a low rate of adverse effects compared with surgery. The authors suggest that SRS may be considered as an alternative treatment for brainstem CMs that are inoperable or have a high operative risk.

Stereotactic radiosurgery of intracranial cavernous malformations

Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. However, there is now sufficient evidence supporting the use of SRS for the difficult cases. Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.