title: Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study.
abstract: OBJECTIVE
  Onyx, an ethylene-vinyl alcohol copolymer mixed in a dimethyl sulfoxide solvent, is currently one of the most widely used liquid materials for embolization of intracranial arteriovenous malformations (AVMs). The goal of this study was to define the risks and benefits of stereotactic radiosurgery (SRS) for patients who have previously undergone partial AVM embolization with Onyx.
  
  
  METHODS
  Among a consecutive series of 199 patients who underwent SRS between January 2007 and December 2012 at the University of Virginia, 25 patients had Onyx embolization prior to SRS (the embolization group). To analyze the obliteration rates and complications, 50 patients who underwent SRS without prior embolization (the no-embolization group) were matched by propensity score method. The matched variables included age, sex, nidus volume before SRS, margin dose, Spetzler-Martin grade, Virginia Radiosurgery AVM Scale score, and median imaging follow-up period.
  
  
  RESULTS
  After Onyx embolization, 18 AVMs were reduced in size. Total obliteration was achieved in 6 cases (24%) at a median of 27.5 months after SRS. In the no-embolization group, total obliteration was achieved in 20 patients (40%) at a median of 22.4 months after SRS. Kaplan-Meier analysis demonstrated obliteration rates of 17.7% and 34.1% in the embolization group at 2 and 4 years, respectively. In the no-embolization group, the corresponding obliteration rates were 27.0% and 55.9%. The between-groups difference in obliteration rates after SRS did not achieve statistical significance. The difference in complications, including adverse radiation effects, hemorrhage episodes, seizure control, and patient mortality also did not reach statistical significance.
  
  
  CONCLUSIONS
  Onyx embolization can effectively reduce the size of many AVMs. This case-control study did not show any statistically significant difference in the rates of embolization or complications after SRS in patients who had previously undergone Onyx embolization and those who had not.
authors: Departments of 1 Neurological Surgery, and.|Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and.|School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
authors: Cheng-Chia
authors: CC
authors: Lee
authors: Departments of 1 Neurological Surgery, and.
authors: Ching-Jen
authors: CJ
authors: Chen
authors: Departments of 1 Neurological Surgery, and.
authors: Benjamin
authors: B
authors: Ball
authors: Departments of 1 Neurological Surgery, and.|Radiation Oncology, University of Virginia, Charlottesville, Virginia;
authors: David
authors: D
authors: Schlesinger
authors: Departments of 1 Neurological Surgery, and.
authors: Zhiyuan
authors: Z
authors: Xu
authors: Departments of 1 Neurological Surgery, and.
authors: Chun-Po
authors: CP
authors: Yen
authors: Departments of 1 Neurological Surgery, and.|Radiation Oncology, University of Virginia, Charlottesville, Virginia;
authors: Jason
authors: J
authors: Sheehan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D002648:Child; D003131:Combined Modality Therapy; D004121:Dimethyl Sulfoxide / Q000627:therapeutic use*; D004338:Drug Combinations; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000473:pathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011145:Polyvinyls / Q000627:therapeutic use*; D016634:Radiosurgery / Q000379:methods*; D013635:Tantalum / Q000627:therapeutic use*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004338:Drug Combinations; C558446:Onyx 18; C000598428:Onyx 34; D011145:Polyvinyls; D013635:Tantalum; D004121:Dimethyl Sulfoxide
keywords: ARE = adverse radiation effect; AVM = arteriovenous malformation; DSA = digital subtraction angiography; EVOH = ethylene-vinyl alcohol; GKS = Gamma Knife surgery; Gamma Knife; LINAC = linear accelerator; MRA = MR angiography; Onyx; PVA = polyvinyl alcohol; RBAS = radiosurgery-based AVM score; SRS = stereotactic radiosurgery; arteriovenous malformation; embolization; nBCA = n-butyl-2-cyanacrylate; obliteration; stereotactic radiosurgery; vascular disorders