ABSTRACT
In 1928, Harvey Cushing was the first to treat arteriovenous malformations (AVMs) using sources of ionizing radiation. Cushing summarized his experience with the statement that radiation therapy for AVMs ‘‘if persisted in, offers considerable promise of amelioration or possibly of cure’’ (1). Although the orthovoltage radioactive sources caused fibrotic and necrotic changes in AVMs, doses to normal brain were high, yielding extensive areas of brain necrosis and significant clinical sequelae. At Stockholm’s Karolinska Hospital in 1951, Leksell introduced stereotactic radiosurgery: noninvasive technology designed to produce a precisely located, well-defined area of necrosis within the brain using a single fraction dose of ionizing radiation (2). This original work included both orthovoltage radiation generators as well as proton beam irradiation. More than a decade later, in 1965, Kjellberg et al. at the Massachusetts General Hospital combined the two approaches and used proton beam irradiation at the Harvard Cyclotron Laboratory (HCL) to perform the first stereotactic radiosurgical treatment of a patient with an AVM (3).
