Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations

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  • 1 Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia;
  • 2 Departments of Neurosurgery and
  • 6 Radiation Oncology, University of Louisville, Kentucky;
  • 3 Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan;
  • 4 Department of Neurosurgery, West Virginia University, Morgantown, West Virginia;
  • 5 Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic;
  • 7 Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio;
  • 8 Department of Radiation Oncology, The Mayo Clinic, Jacksonville, Florida;
  • 9 Department of Neurosurgery, University of Sherbrooke, Canada;
  • 10 Department of Neurosurgery, New York University, New York, New York;
  • 11 Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico;
  • 12 Departments of Neurosurgery and
  • 13 Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania; and
  • 14 Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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OBJECTIVE

Investigations of the combined effects of neoadjuvant Onyx embolization and stereotactic radiosurgery (SRS) on brain arteriovenous malformations (AVMs) have not accounted for initial angioarchitectural features prior to neuroendovascular intervention. The aim of this retrospective, multicenter matched cohort study is to compare the outcomes of SRS with versus without upfront Onyx embolization for AVMs using de novo characteristics of the preembolized nidus.

METHODS

The International Radiosurgery Research Foundation AVM databases from 1987 to 2018 were retrospectively reviewed. Patients were categorized based on AVM treatment approach into Onyx embolization (OE) and SRS (OE+SRS) or SRS alone (SRS-only) cohorts and then propensity score matched in a 1:1 ratio. The primary outcome was AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiological and symptomatic radiation-induced changes (RICs), and cyst formation. Comparisons were analyzed using crude rates and cumulative probabilities adjusted for competing risk of death.

RESULTS

The matched OE+SRS and SRS-only cohorts each comprised 53 patients. Crude rates (37.7% vs 47.2% for the OE+SRS vs SRS-only cohorts, respectively; OR 0.679, p = 0.327) and cumulative probabilities at 3, 4, 5, and 6 years (33.7%, 44.1%, 57.5%, and 65.7% for the OE+SRS cohort vs 34.8%, 45.5%, 59.0%, and 67.1% for the SRS-only cohort, respectively; subhazard ratio 0.961, p = 0.896) of AVM obliteration were similar between the matched cohorts. The secondary outcomes of the matched cohorts were also similar. Asymptomatic and symptomatic embolization-related complication rates in the matched OE+SRS cohort were 18.9% and 9.4%, respectively.

CONCLUSIONS

Pre-SRS AVM embolization with Onyx does not appear to negatively influence outcomes after SRS. These analyses, based on de novo nidal characteristics, thereby refute previous studies that found detrimental effects of Onyx embolization on SRS-induced AVM obliteration. However, given the risks incurred by nidal embolization using Onyx, this neoadjuvant intervention should be used judiciously in multimodal treatment strategies involving SRS for appropriately selected large-volume or angioarchitecturally high-risk AVMs.

ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; CIF = cumulative incidence function; DSA = digital subtraction angiography; OE = Onyx embolization; OR = odds ratio; RIC = radiation-induced change; SHR = subhazard ratio; SRS = stereotactic radiosurgery.

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Contributor Notes

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

INCLUDE WHEN CITING Published online December 11, 2020; DOI: 10.3171/2020.7.JNS201731.

Disclosures Dr. Liscak reports receiving consultant fees from Elekta AB. Dr. Williams reports receiving consultant fees from Monteris Medical, Inc. Dr. Cockroft reports receiving consultant fees from Medtronic and Minnetronix. Dr. Kondziolka reports receiving research funding from Brainlab.

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