Stereotactic Radiosurgery With Versus Without Neoadjuvant Endovascular Embolization for Brain Arteriovenous Malformations With Associated Intracranial Aneurysms

Andrea Becerril-Gaitan; Justin Nguyen; Cheng-Chia Lee; Dale Ding; Christopher P Cifarelli; Roman Liscak; Brian J Williams; Mehran B Yusuf; Shiao Y Woo; Ronald E Warnick; Daniel M Trifiletti; David Mathieu; Douglas Kondziolka; Caleb E Feliciano; Rafel Rodriguez-Mercado; Kevin M Cockroft; Scott Simon; John Lee; Jason P Sheehan; Ching-Jen Chen; International Radiosurgery Research Foundation; International Radiosurgery Research Foundation

doi:10.1227/neu.0000000000003152

Stereotactic Radiosurgery With Versus Without Neoadjuvant Endovascular Embolization for Brain Arteriovenous Malformations With Associated Intracranial Aneurysms

Neurosurgery. 2024 Aug 22. doi: 10.1227/neu.0000000000003152. Online ahead of print.

Authors

Andrea Becerril-Gaitan¹, Justin Nguyen¹, Cheng-Chia Lee^{2

3}, Dale Ding⁴, Christopher P Cifarelli⁵, Roman Liscak⁶, Brian J Williams⁴, Mehran B Yusuf⁷, Shiao Y Woo⁸, Ronald E Warnick⁹, Daniel M Trifiletti¹⁰, David Mathieu¹¹, Douglas Kondziolka¹², Caleb E Feliciano¹³, Rafel Rodriguez-Mercado¹³, Kevin M Cockroft¹⁴, Scott Simon¹⁴, John Lee¹⁵, Jason P Sheehan¹⁵, Ching-Jen Chen¹; International Radiosurgery Research Foundation; International Radiosurgery Research Foundation

Affiliations

¹ Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
² Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.
³ School of Medicine, National Yan-Ming University, Taipei, Taiwan.
⁴ Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
⁵ Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
⁶ Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic.
⁷ Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁸ Department of Radiation Oncology, University of Louisville, Louisville, Kentucky, USA.
⁹ Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio, USA.
¹⁰ Department of Radiation Oncology, The Mayo Clinic, Jacksonville, Florida, USA.
¹¹ Department of Neurosurgery, Centre de recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
¹² Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA.
¹³ Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico, USA.
¹⁴ Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.
¹⁵ Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

PMID: 39171929
DOI: 10.1227/neu.0000000000003152

Abstract

Background and objectives: Stereotactic radiosurgery (SRS) with neoadjuvant embolization is a treatment strategy for brain arteriovenous malformations (AVMs), especially for those with large nidal volume or concomitant aneurysms. The aim of this study was to assess the effects of pre-SRS embolization in AVMs with an associated intracranial aneurysm (IA).

Methods: The International Radiosurgery Research Foundation AVM database from 1987 to 2018 was retrospectively reviewed. SRS-treated AVMs with IAs were included. Patients were categorized into those treated with upfront embolization (E + SRS) vs stand-alone SRS (SRS). Primary end point was a favorable outcome (AVM obliteration + no permanent radiation-induced changes or post-SRS hemorrhage). Secondary outcomes included AVM obliteration, mortality, follow-up modified Rankin Scale, post-SRS hemorrhage, and radiation-induced changes.

Results: Forty four AVM patients with associated IAs were included, of which 23 (52.3%) underwent pre-SRS embolization and 21 (47.7%) SRS only. Significant differences between the E + SRS vs SRS groups were found for AVM maximum diameter (1.5 ± 0.5 vs 1.1 ± 0.4 cm3, P = .019) and SRS treatment volume (9.3 ± 8.3 vs 4.3 ± 3.3 cm3, P = .025). A favorable outcome was achieved in 45.4% of patients in the E + SRS group and 38.1% in the SRS group (P = .625). Obliteration rates were comparable (56.5% for E + SRS vs 47.6% for SRS, P = .555), whereas a higher mortality rate was found in the SRS group (19.1% vs 0%, P = .048). After adjusting for AVM maximum diameter, SRS treatment volume, and maximum radiation dose, the likelihood of achieving favorable outcome and AVM obliteration did not differ between groups (P = .475 and P = .820, respectively).

Conclusion: The likelihood of a favorable outcome and AVM obliteration after SRS with neoadjuvant embolization in AVMs with concomitant IA seems to be comparable with stand-alone SRS, even after adjusting for AVM volume and SRS maximum dose. However, the increased mortality among the stand-alone SRS group and relatively low risk of embolization-related complications suggest that these patients may benefit from a combined treatment approach.