Safety and efficacy of preoperative embolization in the treatment of brain arteriovenous malformations with perinidal aneurysms and single draining vein: a multicenter study with propensity score-weighting

Basel Musmar¹, Nimer Adeeb², Hammam Abdalrazeq², Hamza Adel Salim³, Joanna Roy¹, Stavropoula I Tjoumakaris¹, Sandeep Kandregula⁴, Christopher S Ogilvy⁵, Douglas Kondziolka⁶, Jason P Sheehan⁷, Adam A Dmytriw^{8

9}, Assala Aslan¹⁰, Pious Patel¹, Matthews Lan¹, Michael P Baldassari¹, Sravanthi Koduri¹, Elias Atallah¹, Hussein Zeineddine¹¹, Mary-Katharine Pontarelli¹, Hussam Abou-Al-Shaar¹¹, Kareem El Naamani¹², Ahmed Abdelsalam¹³, Natasha Ironside⁷, Deepak Kumbhare², Sanjeev Gummadi², Mustafa Baskaya¹⁴, Cagdas Ataoglu¹⁴, Finn Mccarthy¹⁵, Anthony Sanchez-Forteza¹⁵, Muhammed Amir Essibayi¹⁶, Abdullah Keles¹⁴, Sandeep Muram⁵, Daniel Sconzo⁵, Howard Riina¹⁷, Arwin Rezai¹⁸, Omar Alwakaa⁵, Salem M Tos⁷, Georgios Mantziaris⁷, Min S Park⁷, Sahin Hanalioglu¹⁹, Ufuk Erginoglu¹⁴, Johannes Pöppe¹⁸, Rajeev D Sen²⁰, Christoph J Griessenauer²¹, Maria Isabel Ocampo-Navia²², Diego A Devia²³, Wilfran Perez-Mendez²², Juan C Puentes^{23

24}, Rahim Abo Kasem²⁵, Alejandro M Spiotta²⁵, Ajit S Puri²⁶, Jasmeet Singh²⁶, Anna Luisa Kuhn²⁷, Jan Karl Burkhardt²⁸, Robert M Starke¹³, Laligam N Sekhar²⁹, Michael Levitt²⁰, David Altschul³⁰, Neil Haranhalli³¹, Malia McAvoy³², Marah Eltiti¹⁰, Abdallah Abushehab³³, Paul Foreman³⁴, Hakeem J Shakir³⁵, Osama O Zaidat³⁶, Mohammad AlMajali³⁷, Marcella Ruppert-Gomez³⁸, Alfred Pokmeng See³⁸, Adib A Abla³⁹, Christopher J Stapleton⁴⁰, Aashay Patel⁴¹, Andrew Nguyen⁴¹, Matthew J Koch⁴¹, Visish M Srinivasan⁴², Peng Roc Chen^{43

44}, Spiros Blackburn⁴⁵, Rabab Alshahrani¹, M Reid Gooch⁴⁶, Robert H Rosenwasser¹, Ketan R Bulsara⁴⁷, Peter Kan⁴⁸, Louis J Kim⁴⁹, Omar Choudhri⁵⁰, Bryan Pukenas⁵¹, Davide Simonato⁵², Yan-Lin Li⁵³, Ali Alaraj⁵⁴, Maurizio Fuschi⁵⁵, Aman B Patel⁵⁶, Amey Savardekar⁵⁷, Christina Notarianni², Hugo H Cuellar^{58

59}, Michael T Lawton⁶⁰, Bharat Guthikonda⁶¹, Jacques Morcos⁶², Pascal Jabbour⁶³

Affiliations

¹ Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
² Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA.
³ Department of Radiology, Division of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
⁴ Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵ Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
⁶ Neurosurgery, New York University Medical Center, New York, New York, USA.
⁷ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
⁸ Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁹ Neuroradiology, Oxford University Hospitals NHS Trust, Oxford, UK.
¹⁰ Radiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA.
¹¹ Neurosurgery, UTHealth Houston, Houston, Texas, USA.
¹² Neurosurgery, Banner Health, Phoenix, Arizona, USA.
¹³ Neurosurgery, University of Miami Health System, Miami, Florida, USA.
¹⁴ Neurosurgery, University of Wisconsin System, Madison, Wisconsin, USA.
¹⁵ Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA.
¹⁶ Neurosurgery, Montefiore Einstein Hospital, New York, New York, USA.
¹⁷ Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA.
¹⁸ Uniklinikum Salzburg - Christian-Doppler-Klinik, Salzburg, Salzburg, Austria.
¹⁹ Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
²⁰ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²¹ University Hospital Salzburg - Christian Doppler Hospital, Salzburg, Salzburg, Austria.
²² Pontificia Universidad Javeriana, Bogotá, Bogota, Colombia.
²³ Neurosurgery, Hospital Universitario San Ignacio, Bogota, Colombia.
²⁴ Radiology, Fundacion Cardioinfantil Instituto de Cardiologia, Bogota, Cundinamarca, Colombia.
²⁵ Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
²⁶ Radiology, University of Massachusetts System, Boston, Massachusetts, USA.
²⁷ Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
²⁸ Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁹ Neurosurgery, University of Washington, Seattle, Washington, USA.
³⁰ Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA.
³¹ Neurosurgery, Montefiore Hospital and Medical Center, Bronx, New York, USA.
³² Neurological Surgery, University of Washington, Seattle, Washington, USA.
³³ Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
³⁴ Orlando Health Corp, Orlando, Florida, USA.
³⁵ Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
³⁶ Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA.
³⁷ Neuroscience, St. Vincent Medical Center, Toledo, Ohio, USA.
³⁸ Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA.
³⁹ Neurological Surgery, University of Miami Health System, Miami, Florida, USA.
⁴⁰ Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁴¹ University of Florida, Gainesville, Florida, USA.
⁴² Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁴³ Neurosurgery, University of Texas John P and Katherine G McGovern Medical School Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁴ Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁵ Neurosurgery, University of Texas Medical School at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴⁷ Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA.
⁴⁸ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
⁴⁹ University of Washington, Seattle, Washington, USA.
⁵⁰ Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
⁵¹ Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵² Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵³ Radiology, Queen Mary Hospital, Hong Kong, Hong Kong.
⁵⁴ Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
⁵⁵ University of Oxford Nuffield Department of Clinical Neurosciences, Oxford, UK.
⁵⁶ Massachusetts General Hospital, Boston, Massachusetts, USA.
⁵⁷ Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA.
⁵⁸ Department of Radiology and Interventional radiology, Ochsner-Louisiana State University, Shreveport, Louisiana, USA.
⁵⁹ Department of Neurosurgery and Interventional Neuroradiology, Ochsner-Louisiana State University, Shreveport, Louisiana, USA.
⁶⁰ Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
⁶¹ LSU Health Shreveport, Shreveport, Louisiana, USA.
⁶² Neurosurgery, UTHealth, Houston, Texas, USA.
⁶³ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA pascal.jabbour@jefferson.edu.

PMID: 40846482
DOI: 10.1136/jnis-2025-023873

Safety and efficacy of preoperative embolization in the treatment of brain arteriovenous malformations with perinidal aneurysms and single draining vein: a multicenter study with propensity score-weighting

Basel Musmar et al. J Neurointerv Surg. 2025.

. 2025 Aug 22:jnis-2025-023873.

doi: 10.1136/jnis-2025-023873. Online ahead of print.

Authors

Affiliations

¹ Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
² Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA.
³ Department of Radiology, Division of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
⁴ Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵ Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
⁶ Neurosurgery, New York University Medical Center, New York, New York, USA.
⁷ Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
⁸ Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁹ Neuroradiology, Oxford University Hospitals NHS Trust, Oxford, UK.
¹⁰ Radiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA.
¹¹ Neurosurgery, UTHealth Houston, Houston, Texas, USA.
¹² Neurosurgery, Banner Health, Phoenix, Arizona, USA.
¹³ Neurosurgery, University of Miami Health System, Miami, Florida, USA.
¹⁴ Neurosurgery, University of Wisconsin System, Madison, Wisconsin, USA.
¹⁵ Neurosurgery, University of Illinois Chicago, Chicago, Illinois, USA.
¹⁶ Neurosurgery, Montefiore Einstein Hospital, New York, New York, USA.
¹⁷ Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA.
¹⁸ Uniklinikum Salzburg - Christian-Doppler-Klinik, Salzburg, Salzburg, Austria.
¹⁹ Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.
²⁰ Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.
²¹ University Hospital Salzburg - Christian Doppler Hospital, Salzburg, Salzburg, Austria.
²² Pontificia Universidad Javeriana, Bogotá, Bogota, Colombia.
²³ Neurosurgery, Hospital Universitario San Ignacio, Bogota, Colombia.
²⁴ Radiology, Fundacion Cardioinfantil Instituto de Cardiologia, Bogota, Cundinamarca, Colombia.
²⁵ Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
²⁶ Radiology, University of Massachusetts System, Boston, Massachusetts, USA.
²⁷ Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
²⁸ Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁹ Neurosurgery, University of Washington, Seattle, Washington, USA.
³⁰ Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, USA.
³¹ Neurosurgery, Montefiore Hospital and Medical Center, Bronx, New York, USA.
³² Neurological Surgery, University of Washington, Seattle, Washington, USA.
³³ Plastic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
³⁴ Orlando Health Corp, Orlando, Florida, USA.
³⁵ Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
³⁶ Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA.
³⁷ Neuroscience, St. Vincent Medical Center, Toledo, Ohio, USA.
³⁸ Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, USA.
³⁹ Neurological Surgery, University of Miami Health System, Miami, Florida, USA.
⁴⁰ Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
⁴¹ University of Florida, Gainesville, Florida, USA.
⁴² Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁴³ Neurosurgery, University of Texas John P and Katherine G McGovern Medical School Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁴ Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁵ Neurosurgery, University of Texas Medical School at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA.
⁴⁶ Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
⁴⁷ Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA.
⁴⁸ Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.
⁴⁹ University of Washington, Seattle, Washington, USA.
⁵⁰ Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
⁵¹ Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵² Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵³ Radiology, Queen Mary Hospital, Hong Kong, Hong Kong.
⁵⁴ Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.
⁵⁵ University of Oxford Nuffield Department of Clinical Neurosciences, Oxford, UK.
⁵⁶ Massachusetts General Hospital, Boston, Massachusetts, USA.
⁵⁷ Neurosurgery, LSU Health Shreveport, Shreveport, Louisiana, USA.
⁵⁸ Department of Radiology and Interventional radiology, Ochsner-Louisiana State University, Shreveport, Louisiana, USA.
⁵⁹ Department of Neurosurgery and Interventional Neuroradiology, Ochsner-Louisiana State University, Shreveport, Louisiana, USA.
⁶⁰ Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
⁶¹ LSU Health Shreveport, Shreveport, Louisiana, USA.
⁶² Neurosurgery, UTHealth, Houston, Texas, USA.
⁶³ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA pascal.jabbour@jefferson.edu.

PMID: 40846482
DOI: 10.1136/jnis-2025-023873

Abstract

Background and objectives: Arteriovenous malformations (AVMs) with perinidal aneurysms and single draining vein are associated with an elevated risk of rupture and increased procedural complexity. The role of preoperative embolization in this high-risk anatomical subset remains unclear. This study aimed to evaluate the safety and efficacy of microsurgery with preoperative embolization, compared with microsurgery alone in patients with such AVMs.

Methods: We conducted a multicenter retrospective analysis of an AVM registry from the MISTA (Multicenter International Study for Treatment of Brain AVMs) consortium and included AVMs with perinidal aneurysms and a single draining vein. Baseline characteristics, angiographic outcomes, functional outcomes, and complication rates were compared. Propensity score weighting (PSW) using the covariate balancing method was applied to adjust for baseline differences.

Results: Out of a total of 1919 patients, 65 met the inclusion criteria; 45 patients underwent preoperative embolization followed by microsurgery, and 20 underwent microsurgery alone. After adjustment, complete obliteration rates were similar between groups (OR 0.87, 95% CI 0.04 to 16.33, P=0.92), as were rates of functional independence at discharge and follow-up. Overall complication, symptomatic complication, and mortality rates did not differ significantly between groups. However, permanent complications were significantly lower in patients with preoperative embolization (OR 0.06, 95% CI 0.004 to 0.84, P=0.03).

Discussion: In patients with AVMs featuring perinidal aneurysms and single draining vein, preoperative embolization followed by microsurgery was associated with fewer permanent complications and no increase in adverse outcomes compared with microsurgery alone. However, given the small number of events, this finding should be interpreted cautiously.

Keywords: Arteriovenous Malformation.

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Conflict of interest statement

Competing interests: None declared.

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Safety and efficacy of preoperative embolization in the treatment of brain arteriovenous malformations with perinidal aneurysms and single draining vein: a multicenter study with propensity score-weighting

Affiliations

Safety and efficacy of preoperative embolization in the treatment of brain arteriovenous malformations with perinidal aneurysms and single draining vein: a multicenter study with propensity score-weighting

Authors

Affiliations

Abstract

Conflict of interest statement

LinkOut - more resources

Full Text Sources

Miscellaneous