Effectiveness of Preradiosurgical Embolization with NBCA for Arteriovenous Malformations - Retrospective Outcome Analysis in a Japanese Registry of 73 Patients (J-REAL study)

PURPOSE Recent reports have posed doubts about the effect of preradiosurgical embolization in brain arteriovenous malformation (AVM) because it makes the planning of stereotactic radiosurgery (SRS) difficult and has the risk of recanalization out of the target. We investigated whether the performance and quality of embolization may influence the success of SRS based on a retrospective case cohort study. MATERIALS AND METHODS Seventy-three patients who underwent embolization followed by SRS between 2003 and 2012 in eight institutes with neurointerventionists were considered. They were divided into the following two groups at 3 years of follow up after the final SRS: "successful occlusion group" (S group), with radiologically complete occlusion of AVM; and "non-successful occlusion group" (N group) with persistent remnant nidus or abnormal vascular networks. Patient background, AVM profile, embolization performance grade and complications were compared in each group. The quality of embolization was evaluated with the new grading system: embolization performance grade (E grade), specializing the achievement of nidus embolization. E grade A was defined as sufficient nidus embolization with more than half of the total number of feeders achieving nidus penetration. E grade B was defined as less than half achievement of nidus embolization, and E grade C was defines as failure to perform nidus embolization. RESULTS Forty-three patients were included in the S group, and 29 patients were included in the N group. The size and Spetzler-Martin grade of AVM and the rate of diffuse type was higher in the N group without statistical significance. The embolization performance level according to E grade indicated a significantly higher rate of successful embolization with more than 50% of nidus penetration in the S group (P<0.001). This difference was also confirmed in the subanalysis for limited cases, excluding smaller AVMs with complete occlusion with SRS alone (P=0.001). CONCLUSION The cause of the unsuccessful result of post-embolization SRS might be the large, diffuse angioarchitecture, but proper embolization with a high rate of nidus penetration to avoid recanalization is more important. Effective embolization is essential to contribute to and promote the effect of radiosurgery.