TY - JOUR
T1 - Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations
AU - Chen, Ching Jen
AU - Ding, Dale
AU - Lee, Cheng Chia
AU - Kearns, Kathryn N.
AU - Pomeraniec, I. Jonathan
AU - Cifarelli, Christopher P.
AU - Arsanious, David E.
AU - Liscak, Roman
AU - Hanuska, Jaromir
AU - Williams, Brian J.
AU - Yusuf, Mehran B.
AU - Woo, Shiao Y.
AU - Ironside, Natasha
AU - Burke, Rebecca M.
AU - Warnick, Ronald E.
AU - Trifiletti, Daniel M.
AU - Mathieu, David
AU - Mureb, Monica
AU - Benjamin, Carolina
AU - Kondziolka, Douglas
AU - Feliciano, Caleb E.
AU - Rodriguez-Mercado, Rafael
AU - Cockroft, Kevin M.
AU - Simon, Scott
AU - Mackley, Heath B.
AU - Zammar, Samer G.
AU - Patel, Neel T.
AU - Padmanaban, Varun
AU - Beatson, Nathan
AU - Saylany, Anissa
AU - Lee, John Y.K.
AU - Sheehan, Jason P.
N1 - Publisher Copyright:
© 2021 American Association of Neurological Surgeons. All rights reserved.
PY - 2021/9
Y1 - 2021/9
N2 - 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. https://thejns.org/doi/abs/10.3171/2020.7.JNS201731.
AB - 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. https://thejns.org/doi/abs/10.3171/2020.7.JNS201731.
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U2 - 10.3171/2020.7.JNS201731
DO - 10.3171/2020.7.JNS201731
M3 - Review article
C2 - 33307527
AN - SCOPUS:85114147299
SN - 0022-3085
VL - 135
SP - 742
EP - 750
JO - Journal of neurosurgery
JF - Journal of neurosurgery
IS - 3
ER -