Embolization of brain arteriovenous malformations with intent to cure: a systematic review

Eva M. Wu Department of Neurological Surgery, University of Texas Southwestern, School of Medicine; and

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Tarek Y. El Ahmadieh Departments of Neurological Surgery and

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Cameron M. McDougall Departments of Neurological Surgery and

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Salah G. Aoun Departments of Neurological Surgery and

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Nikhil Mehta Neurointerventional Radiology, University of Texas Southwestern, Zale Lipshy Hospital, Dallas, Texas

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Om James Neeley Departments of Neurological Surgery and

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Aaron Plitt Departments of Neurological Surgery and

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Vin Shen Ban Departments of Neurological Surgery and

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Rafael Sillero Departments of Neurological Surgery and

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Jonathan A. White Departments of Neurological Surgery and

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H. Hunt Batjer Departments of Neurological Surgery and

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Babu G. Welch Departments of Neurological Surgery and

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OBJECTIVE

Endovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.

METHODS

Electronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.

RESULTS

Fifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.

CONCLUSIONS

While endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

ABBREVIATIONS

AVM = arteriovenous malformation; DACT = double arterial catheterization; DSA = digital subtraction angiography; EVD = external ventricular device; MRA = MR angiography; NBCA = N-butyl cyanoacrylate; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
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Image from Ryu et al. (pp 442–455).

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