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. 2020 Dec 11;135(3):742-750.
doi: 10.3171/2020.7.JNS201731. Print 2021 Sep 1.

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

Ching-Jen Chen  1 , Dale Ding  2 , Cheng-Chia Lee  3 , Kathryn N Kearns  1 , I Jonathan Pomeraniec  1 , Christopher P Cifarelli  4 , David E Arsanious  4 , Roman Liscak  5 , Jaromir Hanuska  5 , Brian J Williams  2 , Mehran B Yusuf  6 , Shiao Y Woo  6 , Natasha Ironside  1 , Rebecca M Burke  1 , Ronald E Warnick  7 , Daniel M Trifiletti  8 , David Mathieu  9 , Monica Mureb  10 , Carolina Benjamin  10 , Douglas Kondziolka  10 , Caleb E Feliciano  11 , Rafael Rodriguez-Mercado  11 , Kevin M Cockroft  12 , Scott Simon  12 , Heath B Mackley  13 , Samer G Zammar  12 , Neel T Patel  12 , Varun Padmanaban  12 , Nathan Beatson  14 , Anissa Saylany  14 , John Y K Lee  14 , Jason P Sheehan  1 ; International Radiosurgery Research Foundation
Affiliations

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

Ching-Jen Chen et al. J Neurosurg. .

Abstract

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.

Keywords: arteriovenous malformation; embolization; endovascular; stereotactic radiosurgery; stroke; vascular disorders.

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Figures

FIG. 1.
FIG. 1.
Comparisons of CIFs for AVM obliteration (p = 0.141) (A), post-SRS hemorrhage (p = 0.314) (B), radiological RICs (p = 0.117) (C), symptomatic RICs (p = 0.048) (D), and cyst development (p = 0.115) (E) between the unmatched OE+SRS versus SRS-only cohorts.
FIG. 2.
FIG. 2.
Comparisons of CIFs for AVM obliteration (p = 0.896) (A), post-SRS hemorrhage (p = 0.950) (B), radiological RICs (p = 0.178) (C), and symptomatic RICs (p = 0.392) (D) between the matched OE+SRS versus SRS-only cohorts.
See this image and copyright information in PMC

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