Microsurgery Versus Stereotactic Radiosurgery for Treatment of Patients With Brain Arteriovenous Malformation: A Systematic Review and Meta-Analysis Publisher Pubmed



Sattari SA¹ ; Shahbandi A² ; Kim JE¹ ; Lee RP¹ ; Feghali J¹ ; Hung A¹ ; Yang W¹ ; Rincontorroella J¹ ; Xu R¹ ; Caplan JM¹ ; Gonzalez LF¹ ; Tamargo RJ¹ ; Huang J¹
Source: Neurosurgery Published:2023

Abstract

BACKGROUND: Treatment decision-making for brain arteriovenous malformations (bAVMs) with microsurgery or stereotactic radiosurgery (SRS) is controversial. OBJECTIVE: To conduct a systematic review and meta-analysis to compare microsurgery vs SRS for bAVMs. METHOD: Medline and PubMed were searched from inception to June 21, 2022. The primary outcomes were obliteration and follow-up hemorrhage, and secondary outcomes were permanent neurological deficit, worsened modified Rankin scale (mRS), follow-up mRS > 2, and mortality. The GRADE approach was used for grading the level of evidence. RESULTS: Eight studies were included, which yielded 817 patients, of which 432 (52.8%) and 385 (47.1%) patients underwent microsurgery and SRS, respectively. Two cohorts were comparable in age, sex, Spetzler-Martin grade, nidus size, location, deep venous drainage, eloquence, and follow-up. In the microsurgery group, the odds ratio (OR) of obliteration was higher (OR = 18.51 [11.05, 31.01], P <.000001, evidence: high) and the hazard ratio of follow-up hemorrhage was lower (hazard ratio = 0.47 [0.23, 0.97], P =.04, evidence: moderate). The OR of permanent neurological deficit was higher with microsurgery (OR = 2.85 [1.63, 4.97], P =.0002, evidence: low), whereas the OR of worsened mRS (OR = 1.24 [0.65, 2.38], P =.52, evidence: moderate), follow-up mRS > 2 (OR = 0.78 [0.36, 1.7], P =.53, evidence: moderate), and mortality (OR = 1.17 [0.41, 3.3], P =.77, evidence: moderate) were comparable between the groups. CONCLUSION: Microsurgery was superior at obliterating bAVMs and preventing further hemorrhage. Despite a higher rate of postoperative neurological deficit with microsurgery, functional status and mortality were comparable with patients who underwent SRS. Microsurgery should remain a first-line consideration for bAVMs, with SRS reserved for inaccessible locations, highly eloquent areas, and medically high-risk or unwilling patients. © 2023 Congress of Neurological Surgeons. All rights reserved.