• Ido Strauss, Oz Haim, Daniel Umansky, Benjamin W Corn, Vladimir Frolov, Natan Shtraus, Shimon Maimon, and Andrew A Kanner.
• The Stereotactic Radiosurgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: idos@tlvmc.gov.il.
• World Neurosurg. 2017 Dec 1; 108: 656-661.

BackgroundStereotactic radiosurgery (SRS) is a well-established treatment modality for cerebral arteriovenous malformations (AVMs). The main limiting factor in the radiosurgical treatment of AVMs is the volume of the nidus, with high-grade lesions often requiring combined treatment to reduce the SRS target volume. To overcome this limitation, we have been using a combined treatment approach consisting of endovascular embolization with Onyx followed by SRS.ObjectiveTo evaluate our clinical experience for safety and feasibility of this multimodality treatment approach.MethodsThis is a retrospective review of all adult patients with cerebral AVMs who received SRS treatment to their AVM after endovascular embolization with Onyx between June 2007 and June 2014.ResultsThirty-five consecutive patients were identified. The mean follow-up period was 52.4 ± 22.6 months (range 18-97 months). We confirmed 18 (51.4%) complete nidus closures at a median time of 49.5 months (range 6.5-81 months) from SRS. High-resolution Magnetic resonance imaging/magnetic resonance angiography was performed routinely in all patients until closure of the nidus. Digital subtraction angiography was performed to confirm complete obliteration in 5 of the patients (28%); 13 patients are either planned for digital subtraction angiography or have refused it. In 6 patients (17%) a significant flow reduction was noted after a mean of 32 ± 16 months. No significant improvement was observed in 9 patients (26%) during the follow-up period. Two patients were lost to follow-up.ConclusionsThe multimodality treatment of cerebral AVMs using embolization with Onyx followed by SRS is feasible and safe. The use of Onyx significantly reduced the SRS treatment target volume.Copyright © 2017 Elsevier Inc. All rights reserved.

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