• Rebeca Pérez-Alfayate, Giovanni Grasso, PérezCristina FernándezCFMethodology and Clinical Epidemiology Unit, Department of Preventive Medicine, Hospital Clínico San Carlos, Madrid, Spain., Javier Arias-Díaz, and Kita Sallabanda-Díaz.
• Department of Neurosurgery, Institute of Neuroscience, Hospital Clínico San Carlos, Madrid, Spain. Electronic address: rebecap.alfayate@gmail.com.
• World Neurosurg. 2021 May 1; 149: e178-e187.

BackgroundThe treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared with other options but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs.MethodsA retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angioarchitectonic variables were collected. Both treatments were compared for the occlusion rate and procedure-related complications. In addition, a cost-effectiveness analysis was performed.ResultsThirty patients (52.6%) were men and 27 (47.4%) were women (mean age, 39 years). AVMs were unruptured in 43 patients (75.4%), and ruptured in 14 patients (24.6%). The presence of deep venous drainage, nidus volume, perforated arterial supply, and eloquent localization was more frequent in the SRS group. Complications such as hemorrhage or worsening of previous seizures were more frequent in the embolization group. No significant differences were observed in the occlusion rates or in the time necessary to achieve occlusion between the groups. The incremental cost-effectiveness ratio for endovascular treatment versus SRS was $53.279.ConclusionsBoth techniques achieved similar occlusion rates, but SRS carried a lower risk of complications. Staged embolization may be associated with a greater risk of hemorrhage, whereas SRS was shown to have a better cost-effectiveness ratio. These results support SRS as a better treatment option for high-grade AVMs.Copyright © 2021 Elsevier Inc. All rights reserved.

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