Multimodality Management in bAVM Surgery - Recent Experience from International Cerebrovascular Fellowship

Analysis of the incidence of death, hemorrhage, and neurological deficit in the treatment of intracranial arteriovenous malformations (AVMs): surgery versus other treatments - a systematic review

To evaluate the incidence of mortality, hemorrhage, and neurological deficits in treating intracranial arteriovenous malformations (AVMs) in patients over 18 through a comparative analysis of surgical approaches and other therapeutic modalities. A systematic review was conducted using MEDLINE, Embase, CENTRAL, and LILACS databases in November 2023. Inclusion criteria included clinical trials, cohorts studies, case-controls studies, and case series comparing patients over 18 undergoing surgery or microsurgery versus other treatments (radiosurgery, isolated embolization, and conservative treatment). Exclusions criteria included studies on non-AVM diseases, non-intracranial AVMs, cavernous malformations, pregnant patients, and those treated with both radiosurgery and microsurgery. Twelve studies included 1,555 patients, with an average age of 42.65 years. Of these, 711 underwent surgery (with or without prior embolization), and 844 underwent other procedures. In the surgery group, the incidence of death was 1.69%, while in the other procedures group, it was 2.96%. The incidence of neurological deficits and hemorrhage in the surgery group was 11.67% and 4.22%, respectively. In other procedures, these incidences were both 9.12%. The average obliteration rate in the surgery group was 97.45%, compared to 49.77% for radiosurgery, 38.46% for isolated embolization, and 0.6% for conservative treatment. This systematic review highlighs that surgery achieves the highest AVM obliteration rates but carries a higher risk neurological déficits. Radiosurgery minimizes these risks, while conservative treatment offers advantages in mortality and hemorrhage reduction. No single modality proves to be universally superior, emphasizing the need for personalized approaches and further randomized trials to clarify comparative safety and efficacy.

Endoscope-assisted microneurosurgery for intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

In the surgical approach to treat deep-seated intracranial lesions, endoscopes can be used to assist microsurgical operations and improve outcomes. This technique is often called endoscope-assisted microneurosurgery (EAM). This systematic review and meta-analysis aimed to evaluate the feasibility, safety, and effectiveness of EAM.

METHODS

We performed a meta-analysis of relevant articles identified using PubMed, Embase, and the Cochrane Central Register to assess the efficacy of EAM according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Primary outcomes were repositioning of the definitive clip, better surgical field, the overall and endoscope-related complication rates, mortality, and the rate of follow up.

RESULTS

A total of 10 studies of 1,432 patients with 1,717 aneurysms treated with EAM were included. EAM led to repositioning of the definitive clip in 13% (95% CI, 9%-17%; I₂ = 72.61%; p < 0.001); 77% of aneurysms treated with endoscopically assisted vision and information had a better outcome than that with standard surgery (95% CI, 52%-95%; I₂ = 97.63%; p < 0.001). There was an overall complication rate of 6% (95% CI, 1%-13%; I₂ = 91.39%; p < 0.001). The incidence of endoscope-related complications was 0% (95% CI, 0%-1%; I₂ = 64%; p < 0.001). The mortality was 0% (95% CI, 0-1%; I₂ = 0.0%); and 94% of patients had an excellent to good recovery and good outcome (95% CI, 88%-98%; I₂ = 88.42%; p < 0.001).

CONCLUSIONS

Our comprehensive study showed that EAM for intracranial aneurysms is feasible, the safety of the surgery is good, and the patients have a good prognosis, Therefore, we think EAM can be more widely adopted in the future.