74 Disability and quality of life following stereotactic radiosurgery for intracranial Arteriovenous malformations — Meta-analysis by mathematical modeling using markov processes

Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001 ). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729 ) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385 ) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.

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Stereotactic radiosurgery with and without embolization for intracranial arteriovenous malformations: a systematic review and meta-analysis

Neurosurgical FOCUS ◽

10.3171/2014.6.focus14178 ◽

2014 ◽

Vol 37 (3) ◽

pp. E16 ◽

Cited By ~ 25

Author(s):

Feng Xu ◽

Junjie Zhong ◽

Abhishek Ray ◽

Sunil Manjila ◽

Nicholas C. Bambakidis

Keyword(s):

Stereotactic Radiosurgery ◽

Arteriovenous Malformations ◽

Meta Analysis ◽

Neurological Deficits ◽

Current Evidence ◽

Secondary Outcome ◽

Intracranial Arteriovenous Malformations ◽

Obliteration Rate ◽

Radiation Induced ◽

Induced Changes

Object The effectiveness and risk of stereotactic radiosurgery (SRS) in the management of partially embolized intracranial arteriovenous malformations (AVMs) remain controversial. The aim of this analysis was to assess current evidence regarding the efficiency and safety of SRS for AVM patients with and without prior embolization. Methods To compare SRS in patients with and without embolization, the authors conducted a meta-analysis of studies by searching the literature via PubMed and EMBASE for the period between January 2000 and December 2013, complemented by a hand search. Primary outcome was the rate of AVM obliteration on a 3-year follow-up angiogram. Secondary outcome was the rate of hemorrhage at 3 years after SRS. Tertiary outcome was permanent neurological deficits related to radiation-induced changes. Results Ten studies eligible for analysis included 1988 patients: 593 had undergone embolization followed by SRS and 1395 had undergone SRS alone. The AVM obliteration rate was significantly lower in patients who had undergone embolization followed by SRS than in those who had undergone SRS alone (41.0% vs 59%, OR 0.46, 95% CI 0.37–0.56, p < 0.00001). However, the rates of hemorrhage (7.3% vs 5.6%, OR 1.17, 95% CI 0.74–1.83, p = 0.50) and permanent neurological deficits related to radiation-induced changes (3.3% vs 3.4%, OR 1.41, 95% CI 0.64–3.11, p = 0.39) were not significantly different between the two groups. Conclusions Embolization before SRS significantly decreases the AVM obliteration rate. However, there is no significant difference in the risk of hemorrhage and permanent neurological deficits after SRS alone and following embolization. Further validation by well-designed prospective or randomized cohort studies is still needed.

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