Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis

Debin Yan, Yu Chen, Zhipeng Li, Haibin Zhang, Ruinan Li, Kexin Yuan, Heze Han, Xiangyu Meng, Hengwei Jin, Dezhi Gao, Youxiang Li, Shibin Sun, Ali Liu, Xiaolin Chen, Yuanli Zhao, Debin Yan, Yu Chen, Zhipeng Li, Haibin Zhang, Ruinan Li, Kexin Yuan, Heze Han, Xiangyu Meng, Hengwei Jin, Dezhi Gao, Youxiang Li, Shibin Sun, Ali Liu, Xiaolin Chen, Yuanli Zhao

Abstract

Objective: Whether partial embolization could facilitate the post-stereotactic radiosurgery (SRS) obliteration for brain arteriovenous malformations (bAVMs) remains controversial. We performed this study to compare the outcomes of SRS with and without prior embolization for bAVMs. Methods: We retrospectively reviewed the Beijing Tiantan AVMs prospective registration research database from September 2011 to October 2014. Patients were categorized into two groups, combined upfront embolization and SRS (Em+SRS group) and SRS alone (SRS group), and we performed a propensity score matching analysis based on pre-embolization baseline characteristics; the matched groups each comprised 76 patients. Results: The obliteration rate was similar between SRS and Em+SRS (44.7 vs. 31.6%; OR, 1.754; 95% CI, 0.905-3.401; p = 0.096). However, the SRS group was superior to the Em+SRS group in terms of cumulative obliteration rate at a follow-up of 5 years (HR,1.778; 95% CI, 1.017-3.110; p = 0.033). The secondary outcomes, including functional state, post-SRS hemorrhage, all-cause mortality, and edema or cyst formation were similar between the matched cohorts. In the ruptured subgroup, the SRS group could achieve higher obliteration rate than Em+SRS group (56.5 vs. 31.9%; OR, 2.773; 95% CI, 1.190-6.464; p = 0.018). The cumulative obliteration rate at 5 years was also higher in the SRS group (64.5 vs. 41.3%; HR, 2.012; 95% CI, 1.037-3.903; p = 0.038), and the secondary outcomes were also similar between the matched cohorts. Conclusion: Although there was no significant difference in the overall obliteration rate between the two strategies, this study suggested that pre-SRS embolization may have a negative effect on post-SRS obliteration. Furthermore, the obliteration rates of the SRS only strategy was significantly higher than that of the Em+SRS strategy in the ruptured cohort, while no such phenomenon was found in the unruptured cohort.

Keywords: brain arteriovenous malformation; hemorrhage; obliteration; partial embolization; stereotactic radiosurgery.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Yan, Chen, Li, Zhang, Li, Yuan, Han, Meng, Jin, Gao, Li, Sun, Liu, Chen and Zhao.

Figures

Figure 1
Figure 1
Patient flowchart demonstrating patient selection and propensity score matching (PSM) process. AVM, arteriovenous malformation; SRS, stereotactic radiosurgery; Em+SRS, prior embolization to stereotactic radiosurgery.
Figure 2
Figure 2
Comparisons of cumulative incidence between SRS and Em+SRS. (A) AVM obliteration. (B) Survival. (C) Post-SRS hemorrhage. (D) Post-SRS complication. AVM, arteriovenous malformation; Em+SRS, embolization + stereotactic radiosurgery. p′-Value refers to the result of a 5-year follow-up.
Figure 3
Figure 3
Comparisons of cumulative incidence in ruptured subgroup between SRS and Em+SRS. (A) AVM obliteration. (C) Post-SRS hemorrhage. Comparisons of cumulative incidence in the unruptured subgroup between SRS and Em+SRS: (B) AVM obliteration. (D) Post-SRS hemorrhage. AVM, arteriovenous malformation; Em+SRS, embolization + stereotactic radiosurgery. p′-Value refers to the result of a 5-year follow-up.

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