Becerril-Gaitan Andrea, Nguyen Justin, Lee Cheng-Chia, Ding Dale, Cifarelli Christopher P, Liscak Roman, Williams Brian J, Yusuf Mehran B, Woo Shiao Y, Warnick Ronald E, Trifiletti Daniel M, Mathieu David, Kondziolka Douglas, Feliciano Caleb E, Rodriguez-Mercado Rafel, Cockroft Kevin M, Simon Scott, Lee John, Sheehan Jason P, Chen Ching-Jen
Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA.
Department of Neurosurgery, Taipei Veterans General Hospital, Taipei , Taiwan.
Neurosurgery. 2025 Apr 1;96(4):787-793. doi: 10.1227/neu.0000000000003152. Epub 2024 Aug 22.
Stereotactic radiosurgery (SRS) with neoadjuvant embolization is a treatment strategy for brain arteriovenous malformations (AVMs), especially for those with large nidal volume or concomitant aneurysms. The aim of this study was to assess the effects of pre-SRS embolization in AVMs with an associated intracranial aneurysm (IA).
The International Radiosurgery Research Foundation AVM database from 1987 to 2018 was retrospectively reviewed. SRS-treated AVMs with IAs were included. Patients were categorized into those treated with upfront embolization (E + SRS) vs stand-alone SRS (SRS). Primary end point was a favorable outcome (AVM obliteration + no permanent radiation-induced changes or post-SRS hemorrhage). Secondary outcomes included AVM obliteration, mortality, follow-up modified Rankin Scale, post-SRS hemorrhage, and radiation-induced changes.
Forty four AVM patients with associated IAs were included, of which 23 (52.3%) underwent pre-SRS embolization and 21 (47.7%) SRS only. Significant differences between the E + SRS vs SRS groups were found for AVM maximum diameter (1.5 ± 0.5 vs 1.1 ± 0.4 cm 3 , P = .019) and SRS treatment volume (9.3 ± 8.3 vs 4.3 ± 3.3 cm 3 , P = .025). A favorable outcome was achieved in 45.4% of patients in the E + SRS group and 38.1% in the SRS group ( P = .625). Obliteration rates were comparable (56.5% for E + SRS vs 47.6% for SRS, P = .555), whereas a higher mortality rate was found in the SRS group (19.1% vs 0%, P = .048). After adjusting for AVM maximum diameter, SRS treatment volume, and maximum radiation dose, the likelihood of achieving favorable outcome and AVM obliteration did not differ between groups ( P = .475 and P = .820, respectively).
The likelihood of a favorable outcome and AVM obliteration after SRS with neoadjuvant embolization in AVMs with concomitant IA seems to be comparable with stand-alone SRS, even after adjusting for AVM volume and SRS maximum dose. However, the increased mortality among the stand-alone SRS group and relatively low risk of embolization-related complications suggest that these patients may benefit from a combined treatment approach.
立体定向放射外科治疗（SRS）联合新辅助栓塞是治疗脑动静脉畸形（AVM）的一种策略，尤其适用于那些巢体积大或伴有动脉瘤的患者。本研究的目的是评估在伴有颅内动脉瘤（IA）的AVM中，SRS前栓塞的效果。
回顾性分析国际放射外科研究基金会1987年至2018年的AVM数据库。纳入接受SRS治疗的伴有IA的AVM患者。患者分为先行栓塞治疗（E+SRS）组和单纯SRS组。主要终点是获得良好结局（AVM闭塞+无永久性放射诱导改变或SRS后出血）。次要结局包括AVM闭塞、死亡率、随访改良Rankin量表评分、SRS后出血和放射诱导改变。
纳入44例伴有IA的AVM患者，其中23例（52.3%）接受了SRS前栓塞，21例（47.7%）仅接受了SRS。E+SRS组与SRS组在AVM最大直径（1.5±0.5 vs 1.1±0.4 cm³，P = 0.019）和SRS治疗体积（9.3±8.3 vs 4.3±3.3 cm³，P = 0.025）方面存在显著差异。E+SRS组45.4%的患者获得了良好结局，SRS组为38.1%（P = 0.625）。闭塞率相当（E+SRS组为56.5%，SRS组为47.6%，P = 0.555），而SRS组的死亡率较高（19.1% vs 0%，P = 0.048）。在调整AVM最大直径、SRS治疗体积和最大放射剂量后，两组获得良好结局和AVM闭塞的可能性无差异（分别为P = 0.475和P = 0.820）。
在伴有IA的AVM中，即使在调整AVM体积和SRS最大剂量后，新辅助栓塞的SRS后获得良好结局和AVM闭塞的可能性似乎与单纯SRS相当。然而，单纯SRS组死亡率增加以及栓塞相关并发症风险相对较低表明，这些患者可能从联合治疗方法中获益。
