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Comparative Study
. 2025 Aug;20(7):852-863.
doi: 10.1177/17474930251323503. Epub 2025 Feb 13.

Comparative outcomes of arteriovenous malformations treatment in eloquent versus non-eloquent brain: A multicenter study with propensity-score weighting

Basel Musmar  1 , Nimer Adeeb  2   3   4 , Hammam Abdalrazeq  2 , Hamza Adel Salim  2 , Joanna M Roy  1 , Assala Aslan  2 , Stavropoula I Tjoumakaris  1 , Christopher S Ogilvy  5 , Mustafa K Baskaya  6 , Douglas Kondziolka  7 , Jason Sheehan  8 , Howard Riina  7 , Sandeep Kandregula  9 , Adam A Dmytriw  10 , Abdallah Abushehab  11 , Kareem El Naamani  1 , Ahmed Abdelsalam  12 , Natasha Ironside  8 , Deepak Kumbhare  3 , Sanjeev Gummadi  3 , Cagdas Ataoglu  6 , Muhammed Amir Essibayi  13 , Abdullah Keles  6 , Sandeep Muram  5 , Daniel Sconzo  5 , Arwin Rezai  14 , Omar Alwakaa  5 , Salem M Tos  8 , Georgios Mantziaris  8 , Min S Park  8 , Sahin Hanalioglu  15 , Ufuk Erginoglu  6 , Johannes Pöppe  14 , Rajeev D Sen  16 , Christoph J Griessenauer  14 , Jan-Karl Burkhardt  9 , Robert M Starke  12 , Laligam N Sekhar  16 , Michael R Levitt  16 , David J Altschul  13 , Neil Haranhalli  13 , Malia McAvoy  16 , Hussein A Zeineddine  4 , Adib A Abla  12 , Elias Atallah  1 , Michael Reid Gooch  1 , Robert H Rosenwasser  1 , Christopher Stapleton  10 , Matthew Koch  17 , Visish M Srinivasan  9 , Peng R Chen  4 , Spiros Blackburn  4 , Ketan Bulsara  18 , Louis J Kim  16 , Omar Choudhri  9 , Bryan Pukenas  9 , Edward Smith  19   20 , Pascal J Mosimann  21 , Ali Alaraj  22 , Mohammad A Aziz-Sultan  15 , Aman B Patel  10 , Amey Savardekar  3 , Christina Notarianni  3 , Hugo H Cuellar  2   3 , Michael Lawton  23 , Bharat Guthikonda  3 , Jacques Morcos  4 , Pascal Jabbour  1
Affiliations
Comparative Study

Comparative outcomes of arteriovenous malformations treatment in eloquent versus non-eloquent brain: A multicenter study with propensity-score weighting

Basel Musmar et al. Int J Stroke. 2025 Aug.

Abstract

Background: Arteriovenous malformations (AVMs) are complex vascular anomalies with a high risk of hemorrhage and neurological deficits, especially when located in eloquent brain regions. The eloquence of an AVM location is a critical factor in the treatment planning, influencing both the risk of complications and long-term functional outcomes. This study aims to compare outcomes between eloquent and non-eloquent AVMs.

Methods: This multicenter, retrospective study utilized data from the Multicenter International Study for Treatment of Brain AVMs (MISTA) consortium. Patients with eloquent and non-eloquent AVMs were compared on baseline characteristics, angiographic outcomes, and functional outcomes using the modified Rankin Scale (mRS). Propensity score weighting (IPTW) was applied to adjust for confounding variables.

Results: The study included 1013 patients, with 498 (49.2%) AVMs located in eloquent regions and 515 (50.8%) in non-eloquent regions. In unadjusted analysis, eloquent AVMs had lower complete obliteration rates (67.6% vs 79.5%, OR: 0.53, 95% CI: 0.39-0.72, p < 0.001) and higher complication rates (24.5% vs 19.0%, OR: 1.38, 95% CI: 1.02-1.86, p = 0.03) compared to non-eloquent AVMs. After IPTW adjustment, eloquent AVMs continued to show significantly higher odds of overall complications (OR: 1.68, 95% CI: 1.12-2.52, p = 0.01) and symptomatic complications (OR: 1.77, 95% CI: 1.12-2.80, p = 0.01). Secondary analysis within the eloquent group indicated that embolization was linked to an elevated risk of complications. Surgery and radiosurgery showed comparable functional outcomes at last follow-up and complications rates with higher complete obliteration rates in surgery.

Conclusion: AVMs in eloquent brain areas present higher risks of complications and lower obliteration rates, emphasizing the need for cautious, individualized treatment planning. Within the eloquent group, embolization increased the risk of complications, while surgery and radiosurgery showed comparable functional outcomes at last follow-up and complication rates with higher complete obliteration rates in surgery. These findings highlight the importance of location in AVM management and support further research focusing on comparing treatment strategies for AVMs in eloquent brain areas.

Keywords: AVM; Eloquent; PSW; multicenter; non-eloquent; treatment.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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