The impact of preradiosurgery embolization on intracranial arteriovenous malformations: a matched cohort analysis based on de novo lesion volume

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OBJECTIVE

The benefits and risks of pre–stereotactic radiosurgery (SRS) embolization have been reported in different studies. The goal of this study was to compare the long-term outcome of arteriovenous malformations (AVMs) treated with and without pre-SRS embolization.

METHODS

A database including 1159 patients with AVMs who underwent SRS was reviewed. The embolized group was selected by including AVMs with pre-SRS embolization, maximal diameter > 30 mm, and estimated volume > 8 ml. The nonembolized group was defined as AVMs treated by SRS alone with matched de novo nidus volume. Outcomes including incidences of favorable clinical outcome (obliteration without hemorrhage, cyst formation, worsening, or new seizures), obliteration, adverse effects, and angioarchitectural complexity were evaluated.

RESULTS

The study cohort comprised 17 patients in the embolized group (median AVM volume 17.0 ml) and 35 patients in the nonembolized group (median AVM volume 13.1 ml). The rates of obliteration (embolized cohort: 33%, 44%, and 56%; nonembolized cohort: 32%, 47%, and 47% at 4, 6, and 10 years, respectively) and favorable outcome were comparable between the 2 groups. However, the embolized group had a significantly higher incidence of repeat SRS (41% vs 23%, p = 0.012) and total procedures (median number of procedures 4 vs 1, p < 0.001), even with a significantly higher margin dose delivered at the first SRS (23 Gy vs 17 Gy, p < 0.001). The median angioarchitectural complexity score was reduced from 7 to 5 after embolization. Collateral flow and neovascularization were more frequently observed in the embolized nonobliterated AVMs.

CONCLUSIONS

Both embolization plus SRS and SRS alone were effective therapies for moderately large (8–39 ml) AVMs. Even with a significantly higher prescription dose at the time of initial SRS, the embolized group still required more procedures to reach final obliteration. The presence of collateral flow and neovascularization could be risk factors for a failure to obliterate following treatment.

ABBREVIATIONS ARE = adverse radiation effect; AVM = arteriovenous malformation; DSA = digital subtraction angiography; HR = hazard ratio; MRA = MR angiography; NBCA = N-butyl cyanoacrylate; SRS = stereotactic radiosurgery; VEGF = vascular endothelial growth factor; VRAS = Virginia Radiosurgery AVM Scale.

Article Information

Correspondence Jason P. Sheehan: University of Virginia, Charlottesville, VA. jsheehan@virginia.edu.

INCLUDE WHEN CITING Published online August 30, 2019; DOI: 10.3171/2019.5.JNS19722.

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.

Headings

Figures

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    A: Flowchart of the patient selection process for the case and control groups. B: Illustrative case 1 (panels a–c). The presence of collateral flow after embolization is shown. This 33-year-old woman had a Spetzler-Martin grade II AVM (3.5 × 3.8 × 5.5 cm) over the right frontal lobe with initial presentation with weakness of the limbs on the left side and hemorrhage. After 8 courses of embolization with Onyx, pre-SRS angiography performed 7 months after the first angiography showed collateral flow feeding for the AVM nidus. Panel a: Preembolization DSA—anteroposterior (AP) projection of right internal carotid artery (ICA) contrast injection showing arterial supply from the right ICA via the right middle cerebral artery (MCA) branch(es). Panel b: Preembolization DSA—AP projection of left ICA contrast injection showing cross-filling of the right anterior cerebral artery (ACA), which supplies the AVM. Panel c: Pre-SRS planning DSA obtained after embolization of nidus and MCA feeders—AP projection of the right ICA showing arterial supply from the right ACA, with interval dilation of the feeders (black arrows). Illustrative case 2 (panels d and e). The presence of neovascularization after embolization is shown. This 23-year-old woman had a Spetzler-Martin grade IV AVM (3.3 × 3.1 × 3.0 cm) over the left frontal lobe and extending to the left basal ganglia with initial presentation with sudden onset of confusion, aphasia, right-sided weakness, and hemorrhage. After 2 courses of embolization with Onyx, pre-SRS angiography performed 3 weeks after the first angiography showed neovascularization of the AVM. Panel d: Preembolization DSA—AP projection of left ICA contrast injection showing arterial supply of the left frontal AVM from the left MCA branch(es) and the lenticulostriate artery (LSA). Panel e: Pre-SRS planning DSA after embolization—AP projection of the right ICA showing neovascularization around the left LSA (black arrow).

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    Kaplan-Meier plot of obliteration rate over time for patients with AVMs who underwent embolization plus SRS (embolized group) versus SRS alone (nonembolized group). The obliteration rates were 13%, 33%, 44%, and 56% (embolization group) and 19%, 32%, 47%, and 47% (nonembolized group) at 2, 4, 6, and 10 years post-SRS, respectively. No statistical difference was noted between the 2 groups (log-rank test, p = 0.432; Mann-Whitney U-test, p = 0.770).

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