Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations

Chen, Ching-Jen; Ding, Dale; Lee, Cheng‐Chia; Kearns, Kathryn N.; Pomeraniec, I. Jonathan; Cifarelli, Christopher P.; Arsanious, David; Hanuška, Jaromír; Williams, Brian J.; Yusuf, Mehran; Woo, Shiao Y.; Ironside, Natasha; Warnick, Ronald E.; Trifiletti, Daniel M.; Mathieu, David; Mureb, Monica; Benjamin, Carolina; Kondziolka, Douglas; Feliciano, Caleb; Rodríguez‐Mercado, Rafael; Cockroft, Kevin M.; Simon, Scott D.; Mackley, Heath B.; Zammar, Samer G.; Patel, Neel; Padmanaban, Varun; Beatson, Nathan; Saylany, Anissa; Lee, John; Sheehan, Jason P.

doi:10.1093/neuros/nyaa418

Cited by 21 publications

(12 citation statements)

References 22 publications

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“…However, Mamalui-Hunter et al (20) and Schlesinger et al (21) confirmed that both Onyx and NBCA had negligible dose perturbation of GKS treatment by constructing physics modeling. Chen et al (12) refuted the prevalent notion that AVM EMB negatively affects the likelihood of obliteration after GKS. There is no statistical difference in terms of final obliteration rate between the combined treatment patients and the GKS patients in this cohort.…”

Section: Discussionmentioning

confidence: 98%

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Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

Meng

Liu

et al. 2021

Front. Neurol.

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Background and purpose: To evaluate whether a radiosurgery-based arteriovenous malformation (AVM) scale (RBAS) could be used to predict obliteration of brain arteriovenous malformations (bAVMs) supposed for combined endovascular embolization (EMB) and gamma knife surgery (GKS) treatment.Methods: bAVM patients who underwent GKS with or without previous EMB from January 2011 to December 2016 at our institution were retrospectively reviewed. The patients were categorized into a combined treatment group and a GKS group. A 1:1 propensity score matching (PSM) was used to match the two groups. Pre-EMB and pre-GKS RBAS were assessed for every patient. Multivariate analysis was performed to find factors associated with complete obliteration in the combined treatment group. Survival analysis based on sub-groups according to RBAS was performed to compare obliteration rate and find cutoffs for appropriate treatment modalities.Results: A total of 96 patients were involved, and each group comprised 48 patients. There was no difference between the two groups in terms of obliteration rate (75.0 vs. 83.3%, p = 0.174). Pre-EMB RBAS (p = 0.010) and the number of feeding arteries (p = 0.014) were independent factors associated with obliteration rate in the combined treatment group. For the combined treatment patients, sub-group analysis according to pre-EMB RBAS (score <1.0, 1.0–1.5, and >1.5) showed statistical difference in obliteration rate (p = 0.002). Sub-group analysis according to RBAS between the two groups showed that the obliteration rate of the GKS group is significantly higher than the combined group when RBAS >1.5 (47.4 vs. 66.7%, p = 0.036).Conclusions: The RBAS is proposed to be efficient in predicting obliteration of bAVMs supposed to receive combined EMB and GKS treatment. Patients with RBAS >1.5 are inclined to be more suitable for GKS instead of the combined treatment.

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Section: Discussionmentioning

confidence: 98%

“…Chen compared the outcomes of EMB and GKS vs. GKS alone for AVMs using pre-EMB malformation features. He concluded that EMB embolization negatively affecting obliteration of GKS is not tenable (12). The debate is still intense, and a combined treatment effect difference among different patient doses exists.…”

Section: Introductionmentioning

confidence: 99%

Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

Meng

Liu

et al. 2021

Front. Neurol.

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“…Whether pre-SRS embolization could facilitate the post-SRS obliteration for bAVMs remain controversial ( 11 – 15 ). We noticed that niduses in the Em+SRS group had higher SM grades and more complicated angioarchitectures when data derived from post-embolization characteristics, rather than pre-embolization lesions, were used as baseline characteristics.…”

Section: Discussionmentioning

confidence: 99%

“…Partial nidus embolization may fragment the nidus into scattered sections, thus, transforming a compact nidus into a diffuse one, and consequently increasing the difficulty of target delineation ( 19 , 20 ). Moreover, embolic agents may suppress the obliteration rates by several mechanisms, including dose reduction by radiation absorption or scattering ( 21 ), obscuration of the residual nidus on post-embolization neuroimaging, and recanalization or pseudo-occlusion ( 11 ). Furthermore, embolization may stimulate and promote angiogenesis of bAVMs, consequently increasing the radioresistance of residual nidus ( 22 , 23 ).…”

Section: Discussionmentioning

confidence: 99%

Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis

Yan

Chen

et al. 2021

Front. Neurol.

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Objective: Whether partial embolization could facilitate the post-stereotactic radiosurgery (SRS) obliteration for brain arteriovenous malformations (bAVMs) remains controversial. We performed this study to compare the outcomes of SRS with and without prior embolization for bAVMs.Methods: We retrospectively reviewed the Beijing Tiantan AVMs prospective registration research database from September 2011 to October 2014. Patients were categorized into two groups, combined upfront embolization and SRS (Em+SRS group) and SRS alone (SRS group), and we performed a propensity score matching analysis based on pre-embolization baseline characteristics; the matched groups each comprised 76 patients.Results: The obliteration rate was similar between SRS and Em+SRS (44.7 vs. 31.6%; OR, 1.754; 95% CI, 0.905–3.401; p = 0.096). However, the SRS group was superior to the Em+SRS group in terms of cumulative obliteration rate at a follow-up of 5 years (HR,1.778; 95% CI, 1.017–3.110; p = 0.033). The secondary outcomes, including functional state, post-SRS hemorrhage, all-cause mortality, and edema or cyst formation were similar between the matched cohorts. In the ruptured subgroup, the SRS group could achieve higher obliteration rate than Em+SRS group (56.5 vs. 31.9%; OR, 2.773; 95% CI, 1.190–6.464; p = 0.018). The cumulative obliteration rate at 5 years was also higher in the SRS group (64.5 vs. 41.3%; HR, 2.012; 95% CI, 1.037–3.903; p = 0.038), and the secondary outcomes were also similar between the matched cohorts.Conclusion: Although there was no significant difference in the overall obliteration rate between the two strategies, this study suggested that pre-SRS embolization may have a negative effect on post-SRS obliteration. Furthermore, the obliteration rates of the SRS only strategy was significantly higher than that of the Em+SRS strategy in the ruptured cohort, while no such phenomenon was found in the unruptured cohort.

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“…However, the authors note symptomatic embolization-related complication rates of 8.3%. 9 Without improvements in clinical outcomes, it remains difficult to justify an increased complication burden.…”

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confidence: 99%

Editorial. To embolize or not to embolize: that is the question for arteriovenous malformations

Başkaya¹,

Richardson²

2021

Neurosurgical Focus: Video

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owlati et al. presented a case of a cerebellopontine angle, Spetzler-Martin grade II arteriovenous malformation (AVM), where they clearly demonstrated the key surgical points. 1 We commend the authors on the clinical and radiologic outcome for this patient. The patient initially presented with AVM rupture and underwent external ventricular drain placement and suboccipital decompression with hematoma evacuation. Following a diagnostic angiogram to better characterize the AVM, he was treated with two stages of embolization, without complication, at an outside hospital. However, the embolic material did not completely penetrate the AVM nidus. Follow-up angiography at 4 months demonstrated continued arteriovenous shunting and recruitment of additional dural feeders. Resection was thus recommended and was completed via a retrosigmoid craniotomy. The patient recovered well, with postoperative angiography demonstrating complete resolution of the AVM. 1 Fortunately, this patient recovered well. He had no complications from his diagnostic angiogram, from either the embolization procedure or the definitive microsurgical resection of the AVM. Diagnostic angiography is a key step in the workup for cerebral AVMs to define the feeding vessels and venous drainage and identify any high-risk features. Controversy remains regarding the role of embolization in the treatment of cerebral AVMs. All procedures-endovascular or surgical-carry risk. The question with AVMs is, is the risk of complications associated with embolization worth the benefit?Embolization of cerebral AVMs may be performed for several reasons. AVMs may be embolized with curative intent, as a preoperative adjunct, as an adjunctive treatment prior to radiosurgery, or for palliative treatment. The choice to embolize, and for what purpose, is guided by the nature of each particular AVM, where the feeders are, and the Spetzler-Martin grade. In one series of AVM embolizations that were performed for any indication, the rate of

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Stereotactic Radiosurgery With Versus Without Embolization for Brain Arteriovenous Malformations

Cited by 21 publications

References 22 publications

Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations

Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis

Editorial. To embolize or not to embolize: that is the question for arteriovenous malformations

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