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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Burke RM, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee JYK, Sheehan JP. Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations. J Neurosurg 2021; 135:742-750. [PMID: 33307527 PMCID: PMC8192588 DOI: 10.3171/2020.7.jns201731] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigations of the combined effects of neoadjuvant Onyx embolization and stereotactic radiosurgery (SRS) on brain arteriovenous malformations (AVMs) have not accounted for initial angioarchitectural features prior to neuroendovascular intervention. The aim of this retrospective, multicenter matched cohort study is to compare the outcomes of SRS with versus without upfront Onyx embolization for AVMs using de novo characteristics of the preembolized nidus. METHODS The International Radiosurgery Research Foundation AVM databases from 1987 to 2018 were retrospectively reviewed. Patients were categorized based on AVM treatment approach into Onyx embolization (OE) and SRS (OE+SRS) or SRS alone (SRS-only) cohorts and then propensity score matched in a 1:1 ratio. The primary outcome was AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiological and symptomatic radiation-induced changes (RICs), and cyst formation. Comparisons were analyzed using crude rates and cumulative probabilities adjusted for competing risk of death. RESULTS The matched OE+SRS and SRS-only cohorts each comprised 53 patients. Crude rates (37.7% vs 47.2% for the OE+SRS vs SRS-only cohorts, respectively; OR 0.679, p = 0.327) and cumulative probabilities at 3, 4, 5, and 6 years (33.7%, 44.1%, 57.5%, and 65.7% for the OE+SRS cohort vs 34.8%, 45.5%, 59.0%, and 67.1% for the SRS-only cohort, respectively; subhazard ratio 0.961, p = 0.896) of AVM obliteration were similar between the matched cohorts. The secondary outcomes of the matched cohorts were also similar. Asymptomatic and symptomatic embolization-related complication rates in the matched OE+SRS cohort were 18.9% and 9.4%, respectively. CONCLUSIONS Pre-SRS AVM embolization with Onyx does not appear to negatively influence outcomes after SRS. These analyses, based on de novo nidal characteristics, thereby refute previous studies that found detrimental effects of Onyx embolization on SRS-induced AVM obliteration. However, given the risks incurred by nidal embolization using Onyx, this neoadjuvant intervention should be used judiciously in multimodal treatment strategies involving SRS for appropriately selected large-volume or angioarchitecturally high-risk AVMs.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N. Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David E. Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Mehran B. Yusuf
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Shiao Y. Woo
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Rebecca M. Burke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David Mathieu
- Department of Neurosurgery, University of Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E. Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M. Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B. Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G. Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T. Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee J, Sheehan JP. Embolization of Brain Arteriovenous Malformations With Versus Without Onyx Before Stereotactic Radiosurgery. Neurosurgery 2021; 88:366-374. [PMID: 32860409 DOI: 10.1093/neuros/nyaa370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/24/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Embolization of brain arteriovenous malformations (AVMs) using ethylene-vinyl alcohol copolymer (Onyx) embolization may influence the treatment effects of stereotactic radiosurgery (SRS) differently than other embolysates. OBJECTIVE To compare the outcomes of pre-SRS AVM embolization with vs without Onyx through a multicenter, retrospective matched cohort study. METHODS We retrospectively reviewed International Radiosurgery Research Foundation AVM databases from 1987 to 2018. Embolized AVMs treated with SRS were selected and categorized based on embolysate usage into Onyx embolization (OE + SRS) or non-Onyx embolization (NOE + SRS) cohorts. The 2 cohorts were matched in a 1:1 ratio using de novo AVM features for comparative analysis of outcomes. RESULTS The matched cohorts each comprised 45 patients. Crude AVM obliteration rates were similar between the matched OE + SRS vs NOE + SRS cohorts (47% vs 51%; odds ratio [OR] = 0.837, P = .673). Cumulative probabilities of obliteration were also similar between the OE + SRS vs NOE + SRS cohorts (subhazard ratio = 0.992, P = .980). Rates of post-SRS hemorrhage, all-cause mortality, radiation-induced changes, cyst formation, and embolization-associated complications were similar between the matched cohorts. Sensitivity analysis for AVMs in the OE + SRS cohort embolized with Onyx alone revealed a higher rate of asymptomatic embolization-associated complications in this subgroup compared to the NOE + SRS cohort (36% vs 15%; OR = 3.297, P = .034), but the symptomatic complication rates were similar. CONCLUSION Nidal embolization using Onyx does not appear to differentially impact the outcomes of AVM SRS compared with non-Onyx embolysates. The embolic agent selected for pre-SRS AVM embolization should reflect both the experience of the neurointerventionalist and target of endovascular intervention.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - I Jonathan Pomeraniec
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - David E Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Shiao Y Woo
- Department of Radiation Oncology, University of Louisville, Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Ronald E Warnick
- Department of Neurosurgery, The Jewish Hospital, Cincinnati, Ohio
| | | | - David Mathieu
- Department of Neurosurgery, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Nerva JD, Barber J, Levitt MR, Rockhill JK, Hallam DK, Ghodke BV, Sekhar LN, Kim LJ. Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm. J Neurointerv Surg 2017; 10:258-267. [PMID: 28710086 DOI: 10.1136/neurintsurg-2017-013084] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial. OBJECTIVE To compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone. METHODS Seventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication. RESULTS Forty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively. CONCLUSION Pre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.
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Affiliation(s)
- John D Nerva
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA.,Department of Mechanical Engineering, University of Washington, Washington, USA
| | - Jason K Rockhill
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiation Oncology, University of Washington, Washington, USA
| | - Danial K Hallam
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Basavaraj V Ghodke
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Laligam N Sekhar
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Washington, USA.,Department of Radiology, University of Washington, Washington, USA
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