The gradual broadening of indications for radiosurgery was not driven by scientific considerations. Neurosurgeons, usually in charge of the gamma knife in their respective institutions, were all too aware of the complications encountered in open surgical management of their patients, and so the more "high surgical risk" conditions were referred for the alternative. This was the main explanation for the emergence and rise of AVM radiosurgery. The initial few, tentative, referrals were followed by increasing numbers when the general advantages of radiosurgery and the good results became apparent. The second driving force was the evolution that took place in the hearts and minds of patients who obtain information from the Internet and other sources. This is most apparent in patients with benign conditions, e.g. vestibular schwannomas. These patients have the time to research their condition and to enquire about side-effects and complications and compare those with different interventions. They encounter their brethren through patient organizations. Such personal observations may be biased but often prove decisive. Patients tend to make up their minds based on perception and emotional reasons and not leave to their surgeon or to chance the decision as to whether to have major brain surgery or undergo a day-case procedure. Patient pressure is a very powerful force.

Scientific evidence in the form of prospective randomized controlled trials is lacking for both surgery and radiosurgery for most pathologies. Given the problems in recruiting sufficient numbers for the trials, and problems with patients dropping out and crossing over, such data are unlikely to become available. On the other hand, case series provide useful data. The strength of radiosurgery publications is the easy reproducibility of the results in similar units; quite the opposite would apply to microsurgical results published only from centers of excellence, with average and poorer results never becoming available.

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