Stereotactic radiosurgery with and without embolization for intracranial arteriovenous malformations: a systematic review and meta-analysis

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The effectiveness and risk of stereotactic radiosurgery (SRS) in the management of partially embolized intracranial arteriovenous malformations (AVMs) remain controversial. The aim of this analysis was to assess current evidence regarding the efficiency and safety of SRS for AVM patients with and without prior embolization.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>To compare SRS in patients with and without embolization, the authors conducted a meta-analysis of studies by searching the literature via PubMed and EMBASE for the period between January 2000 and December 2013, complemented by a hand search. Primary outcome was the rate of AVM obliteration on a 3-year follow-up angiogram. Secondary outcome was the rate of hemorrhage at 3 years after SRS. Tertiary outcome was permanent neurological deficits related to radiation-induced changes.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Ten studies eligible for analysis included 1988 patients: 593 had undergone embolization followed by SRS and 1395 had undergone SRS alone. The AVM obliteration rate was significantly lower in patients who had undergone embolization followed by SRS than in those who had undergone SRS alone (41.0% vs 59%, OR 0.46, 95% CI 0.37–0.56, p &lt; 0.00001). However, the rates of hemorrhage (7.3% vs 5.6%, OR 1.17, 95% CI 0.74–1.83, p = 0.50) and permanent neurological deficits related to radiation-induced changes (3.3% vs 3.4%, OR 1.41, 95% CI 0.64–3.11, p = 0.39) were not significantly different between the two groups.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Embolization before SRS significantly decreases the AVM obliteration rate. However, there is no significant difference in the risk of hemorrhage and permanent neurological deficits after SRS alone and following embolization. Further validation by well-designed prospective or randomized cohort studies is still needed.</jats:p></jats:sec>

Repeat radiosurgery for cerebral arteriovenous malformations

“…[6-9] Radiosurgery is an accepted treatment modality for AVM located in eloquent cortex or deep brain structures. [10-14]…”

Stereotactic Radiosurgery for Brain Arteriovenous Malformations

“…A meta-analysis including 10 studies with a total of 1,988 patients demonstrated that the obliteration rate was significantly lower in patients who had undergone embolization followed by SRS comparing to patients who had undergone SRS alone (41% vs 59%). The relative higher hemorrhage rate after combined treatment in this report may be partially explained by fact that nidus size and AVMs volumes were larger in the embolization group than in the nonembolized group 56 .…”

“…The association is also useful for those lesions larger than 3 cm that cannot be treated by SRS alone, since the complete cure of AVMs by embolization is not the rule 3 . The concept of nidus volume reduction by endovascular treatment, making the lesion ideal for SRS, has been the only treatment option for many AVMs 3,17,20,56,63 . Although the unquestionable advantages of this association, some pitfalls have already been demonstrated in the literature.…”

Complications of Endovascular Treatments for Brain Arteriovenous Malformations: A Nationwide Surveillance

“…Considering that embolization before radiosurgery can decrease the rate of AVM obliteration, preradiosurgical AVM embolization should be decided prudently. 29 Patients with infratentorial AVMs have worse outcomes than those with supratentorial lesions. 30 They are more likely to present with hemorrhage, with annual rates of hemorrhage ranging from 4.4% to 11.6%, compared with all AVMs (2%-4%), and with an annual rehemorrhage rate of 34.4% for ruptured AVMs managed conservatively.…”