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Endovascular treatment as first-line therapy in Spetzler-Martin grade III brain arteriovenous malformations: a
Mariana L DE Bastos Maximiano1, Ocílio R Gonçalves2, Luciano Falcão3
1Federal Fluminense University, Rio de Janeiro, Brazil.
Background:
Spetzler-Martin (SM) grade III brain arteriovenous malformations (AVMs) present a therapeutic challenge due to their risk profile. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of endovascular treatment (EVT) as first-line therapy for these lesions.
Methods:
We searched PubMed, Embase, Cochrane CENTRAL, and Web of Science from inception to January 2025. Eligible studies were observational, enrolled patients with SM grade III AVMs undergoing EVT, and reported clinical or radiological outcomes. Primary endpoints included obliteration rate, functional outcome, and adverse events. Random-effects models were used to calculate pooled proportions with 95% confidence intervals (CI). Heterogeneity was assessed with I2. Statistical analysis was conducted in R® version 4.4.0.
Results:
Nineteen studies (N.=1105; SM grade III: N.=588) were included. EVT achieved complete immediate obliteration in 51% (95% CI: 30-72%; I2=95%), while residual nidus persisted in 39% (95% CI: 19-60%). Functional independence (mRS 0-2) was reached in 96% (95% CI: 90%-99%; I2=32%), whereas poor functional outcome (mRS ≥3) occurred in 5% of patients (95% CI: 1-11%). Permanent neurological deficits were reported in 5% (95% CI: 1-12%), and procedural complications occurred in 14% (95% CI: 7-22%). Mortality and recurrence rates were both 0%. Adjunctive therapies were required in 49% of cases (95% CI: 26-73%). Rebleeding during follow-up occurred in 7% (95% CI: 2-15%).
Conclusions:
EVT as first-line therapy for SM grade III AVMs is associated with high functional independence, moderate obliteration rates, low permanent morbidity, and negligible mortality, although nearly half of patients require adjunctive treatment.
