Comparative Outcomes of Arteriovenous Malformations treatment in Eloquent versus Non-Eloquent Brain: A Multicenter Study with Propensity-Score Weighting
Authors: Musmar Basel , Adeeb Nimer , Abdalrazeq Hammam , Salim Hamza A. , Roy Joanna M. , Aslan Assala , Tjoumakaris Stavropoula I , Ogilvy Christopher , Baskaya Mustafa K. , Kondziolka Douglas , Sheehan Jason , Riina Howard , Kandregula Sandeep , Dmytriw Adam , Abushehab Abdallah , El Naamani Kareem , Abdelsalam Ahmed , Ironside Natasha , Kumbhare Deepak , Gummadi Sanjeev , Ataoglu Cagdas , Essibayi Muhammed Amir , Keles Abdullah , Muram Sandeep , Sconzo Daniel , Rezai Arwin , Alwakaa Omar , Tos Salem M , Mantziaris Georgios , Park Min S , Hanalioglu Sahin , Erginoglu Ufuk , Pöppe Johannes , Sen Rajeev D. , Griessenaur Christoph , Burkhardt Jan-Karl , Starke Robert M. , Sekhar Laligam N. , Levitt Michael R. , Altschul David , Haranhalli Neil , McAvoy Malia , Zeineddine Hussein A. , Abla Adib A. , Atallah Elias , Gooch Michael Reid , Rosenwasser Robert H , Stapleton Christopher J , Koch Matthew , Srinivasan Visish M. , Chen Peng Roc , Blackburn Spiros , Bulsara Ketan , Kim Louis J. , Choudhri Omar , Pukenas Bryan , Smith Edward , Mosimann Pascal J. , Alaraj Ali , Aziz-Sultan Mohammad Ali , Patel Aman B , Savardekar Amey Rajan , Notarianni Christina , Cuellar Hugo , Lawton Michael T. , Guthikonda Bharat , Morcos Jacques , Jabbour Pascal 
Published: February 2025

Background: Arteriovenous malformations (AVMs) are complex vascular anomalies with a high risk of hemorrhage and neurological deficits, especially when located in eloquent brain regions. The eloquence of an AVM location is a critical factor in the treatment planning, influencing both the risk of complications and long-term functional outcomes. This study aims to compare outcomes between eloquent and non-eloquent AVMs. Methods: This multicenter, retrospective study utilized data from the Multicenter International Study for Treatment of Brain AVMs (MISTA) consortium. Patients with eloquent and non-eloquent AVMs were compared on baseline characteristics, angiographic outcomes, and functional outcomes using the modified Rankin Scale (mRS). Propensity score weighting (IPTW) was applied to adjust for confounding variables. Results: The study included 1,013 patients, with 498 (49.2%) AVMs located in eloquent regions and 515 (50.8%) in non-eloquent regions. In unadjusted analysis, eloquent AVMs had lower complete obliteration rates (67.6% vs. 79.5%, OR: 0.53, 95% CI: 0.39–0.72, p < 0.001) and higher complication rates (24.5% vs. 19.0%, OR: 1.38, 95% CI: 1.02–1.86, p = 0.03) compared to non-eloquent AVMs. After IPTW adjustment, eloquent AVMs continued to show significantly higher odds of overall complications (OR: 1.68, 95% CI: 1.12–2.52, p = 0.01) and symptomatic complications (OR: 1.77, 95% CI: 1.12–2.80, p = 0.01). Secondary analysis within the eloquent group indicated that embolization was linked to an elevated risk of complications. Surgery and radiosurgery showed comparable functional outcomes at last follow-up and complications rates with higher complete obliteration rates in surgery. Conclusion: AVMs in eloquent brain areas present higher risks of complications and lower obliteration rates, emphasizing the need for cautious, individualized treatment planning. Within the eloquent group, embolization increased the risk of complications, while surgery and radiosurgery showed comparable functional outcomes at last follow-up and complication rates with higher complete obliteration rates in surgery. These findings highlight the importance of location in AVM management and support further research focusing on comparing treatment strategies for AVMs in eloquent brain areas.