Abstract
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.
Highlights
Intracranial arteriovenous malformations (IAVMs) are congenital, heterogeneous, and rare vascular abnormalities that can cause intracranial hemorrhage, headache, seizure, and death [1]
The study was included if they met all the inclusion criteria: (1) patients, all patients diagnosed with IAVMs, irrespective of disease status; (2) intervention, stereotactic radiosurgery (SRS) following embolization; (3) control, SRS alone; (4) outcomes, the study reported on obliteration rate, rehemorrhage rate, or permanent neurological deficits; and (5) study design, original article and unrestricted design type
The remaining 85 studies were retrieved for further full-text evaluations, and 66 studies were excluded owing to inappropriate control (n = 35), other disease statuses (n = 19), and insufficient data (n = 12)
Summary
Intracranial arteriovenous malformations (IAVMs) are congenital, heterogeneous, and rare vascular abnormalities that can cause intracranial hemorrhage, headache, seizure, and death [1]. IAVMs with an abnormal nidus of blood vessels shunt blood from the arterial to the venous system and bypass an intervening capillary bed [2]. These lesions account for 2–3% of symptomatic hemorrhages, and the hemorrhage rate was 2–4% annually when patients were left untreated [3, 4]. Endovascular embolization prior to SRS should introduce as a neurointerventional minimally invasive approach for patients with IAVMs. endovascular embolization rarely provided complete treatment for IAVMs, it could improve the natural history of patients at high risk of hemorrhage owing to intranidal or perinodal aneurysms and large venous varices [20,21,22]. The current systematic review and meta-analysis were conducted to obtain a comprehensive, quantitative evidence to compare the efficacy and safety of SRS following embolization with SRS alone in patients with IAVM new results
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