Hypofractionated radiosurgery can thread the needle between efficacy and adverse effects for larger or eloquent arteriovenous malformations (AVM) where single-fraction radiosurgery cannot. This technical review pooled 10 retrospective series (n=370) evaluating fractionated radiosurgery for intracranial AVMs delivered 1986–2024. Across studies, regimens around 30–32.5 Gy in 5 fractions appeared to hit the sweet spot, yielding obliteration rates in the 70–80% range for AVMs <15–20 cc with relatively low rates of symptomatic radionecrosis (<5%). Below ~30 Gy, obliteration rates cratered; beyond ~35 Gy, adverse effects climbed sharply including symptomatic radionecrosis rates approaching 10–30% in some series. Larger AVMs (>20 cc) remain a challenge, with obliteration rates often <30–40% despite treatment, suggesting radiation is best used here as an adjunctive–rather than stand-alone–strategy. The review also highlights the modern evolution of AVM radiosurgery workflows: frameless immobilization, MRI-based planning, VMAT delivery, and less reliance on stereotactic angiography except in complex cases. | Belaidi, Pract Radiat Oncol 2026
