Stereotactic radiosurgery alone or combined with embolization for brain arteriovenous malformations: a systematic review and meta-analysis

Restricted access


Embolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).


A literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.


Twelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.


Arteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.

ABBREVIATIONS ARE = adverse radiation effect; AVM = arteriovenous malformation; E+SRS = embolization plus stereotactic radiosurgery; GKS = Gamma Knife surgery; SRS = stereotactic radiosurgery.

Article Information

Correspondence Jason Sheehan, Department of Neurological Surgery, University of Virginia, Box 800212, Charlottesville, VA 22908. email

INCLUDE WHEN CITING Published online May 12, 2017; DOI: 10.3171/2016.11.JNS162382.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Flowchart demonstrating the literature review process during which 675 articles were identified on PubMed by using the search criteria. After excluding articles because of inappropriate subject matter, insufficient outcome data, or inappropriate data presentation, 12 articles comprising 1716 suitable patients remained for meta-analysis.

  • View in gallery

    The individual studies are listed chronologically with their corresponding weight. Results of the meta-analysis are noted at the bottom of the table. An OR of 0.51 (95% CI 0.41–0.64) was calculated by meta-analysis. GKRS = Gamma Knife radiosurgery; M-H = Mantel-Haenszel. Figure is available in color online only.



Cited By



All Time Past Year Past 30 Days
Abstract Views 218 218 23
Full Text Views 372 372 14
PDF Downloads 194 194 10
EPUB Downloads 0 0 0


Google Scholar