BACKGROUND AND OBJECTIVES: 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). METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Department of Neurosurgery Centre de recherche du CHUS Université de Sherbrooke Sherbrooke Quebec Canada

Department of Neurosurgery New York University Langone Medical Center New York New York USA

Department of Neurosurgery Penn State Hershey Medical Center Hershey Pennsylvania USA

Department of Neurosurgery Taipei Veterans General Hospital Taipei Taiwan

Department of Neurosurgery The University of Texas Health Science Center at Houston Houston Texas USA

Department of Neurosurgery University of Louisville Louisville Kentucky USA

Department of Neurosurgery University of Pennsylvania Philadelphia Pennsylvania USA

Department of Neurosurgery University of Puerto Rico San Juan Puerto Rico USA

Department of Neurosurgery West Virginia University Morgantown West Virginia USA

Department of Radiation Oncology The Mayo Clinic Jacksonville Florida USA

Department of Radiation Oncology University of Alabama at Birmingham Birmingham Alabama USA

Department of Radiation Oncology University of Louisville Louisville Kentucky USA

Department of Stereotactic and Radiation Neurosurgery Na Homolce Hospital Prague Czech Republic

Gamma Knife Center Jewish Hospital Mayfield Clinic Cincinnati Ohio USA

School of Medicine National Yan Ming University Taipei Taiwan

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