Embolization followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs)

Abstract Background Embolization has been proposed to reduce the size of the AVM nidus in advance of radiosurgical treatment. However, embolization followed by radiosurgery for brain AVMs is controversial. Objective This study assessed the impact of embolization on nidal size prior to radiosurgical...

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Published in:	World neurosurgery 2017-03, Vol.99, p.471-476
Main Authors:	Marks, Michael P., M.D, Marcellus, Mary L, Santarelli, Justin, M.D, Dodd, Robert L., M.D. PhD, Do, Huy M., M.D, Chang, Steven D., M.D, Adler, John R., M.D, Mlynash, Michael, M.D. MS, Steinberg, Gary K., M.D. PhD
Format:	Article
Language:	eng
Subjects:	Adolescent Adult Aged Arteriovenous malformation (AVM) Cerebral Angiography Child Combined Modality Therapy Embolization Embolization, Therapeutic - methods Female Follow-Up Studies Headache - etiology Humans Intracranial Arteriovenous Malformations - complications Intracranial Arteriovenous Malformations - therapy Intracranial Hemorrhages - etiology Male Middle Aged Neurosurgery Radiosurgery Radiosurgery - methods Retrospective Studies Seizures - etiology Treatment Outcome Young Adult
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Summary:	Abstract Background Embolization has been proposed to reduce the size of the AVM nidus in advance of radiosurgical treatment. However, embolization followed by radiosurgery for brain AVMs is controversial. Objective This study assessed the impact of embolization on nidal size prior to radiosurgical treatment and evaluated cure rates and complications using embolization followed by radiosurgery. Methods Retrospective review of our institutional AVM database identified 91 patients treated from 1995-2009 with embolization followed by radiosurgery. Pre- and post-embolization AVM volumes were measured with angiography and the modified Radiation-Based AVM scores (RBAS) were was also calculated pre and post-embolization. RBAS determined from pre-embolization volumes were correlated with post-radiosurgical obliteration. Results Median AVM volume declined from 18.8 (IQR, 10.2-32.2) ml to 9.9 (3.1-19.2) ml following embolization, P < 0.00003. Median RBAS scores decreased from 2.6 (1.8-3.9) ml to 1.8 (1.0-2.8), P < 0.00003. Two of 91 (2.2 %) had new fixed deficits following embolization, however no patient had new disabling deficits (mRS>2). 71 of 91(79%) have had >3 year follow-up and 40 (56%) had complete obliteration with 38 (53%) having excellent outcomes (complete obliteration without neurologic decline). Excellent outcome was seen in 90% of patients with modified RBAS score 2. Conclusion These data suggest that embolization of brain AVMs can safely and effectively reduce the treatment volume prior to radiosurgery. Combined therapy with embolization and radiosurgery does not appear to adversely affect rates of excellent outcome.
ISSN:	1878-8750 1878-8769