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Adenosine-assisted embolization of cerebral arteriovenous malformations: a systematic review and meta-analysis
  1. Jhon E Bocanegra-Becerra1,
  2. Filipi Fim Andreão2,
  3. José Luis Acha Sánchez3,
  4. Anuraag Punukollu4,
  5. Leonardo B Oliveira5,
  6. Krish Kuhar6,
  7. Maria Eduarda Rodrigues Peixoto7,
  8. Elizabet Taylor Pimenta Weba8,
  9. Khaled Alhwaishel9,
  10. Marcio Yuri Ferreira10,
  11. Raphael Bertani11,
  12. Miguel Angel Lopez-Gonzalez12
    1. 1Academic Department of Surgery, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
    2. 2Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
    3. 3Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru
    4. 4Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
    5. 5Department of Medicine, State University of Ponta Grossa, Ponta Grossa, Brazil
    6. 6Dr Baba Saheb Ambedkar Hospital, Delhi, India
    7. 7Federal University of Tocantins, Palmas, Brazil
    8. 8Universidade Estadual da Regiao Tocantina do Maranhao, Imperatriz, Brazil
    9. 9Mansoura Manchester Program, Faculty of Medicine, Mansoura University, Mansoura, Egypt
    10. 10Department of Neurosurgery, Lenox Hill Hospital/Northwell Health, New York, NY, USA
    11. 11Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
    12. 12Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, USA
    1. Correspondence to Dr Jhon E Bocanegra-Becerra, Academic Department of Surgery, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, 15102, Peru; jhon.bocanegra.b{at}


    Background Cerebral arteriovenous malformations (AVMs) are complex lesions that can cause hemorrhagic stroke and significant neurological disability. Adenosine induces cardiac standstill and hypotension, which are thought to be useful during cerebral AVM embolization. Herein, we conducted a systematic review and meta-analysis of the technique’s safety.

    Methods Following PRISMA guidelines, four databases were queried for studies describing the use of adenosine-assisted embolization of cerebral AVMs. Adenosine-related intraoperative complications, permanent neurological outcomes, morbidity, and mortality assessed the technique’s safety. Single proportion analysis under a random-effects model was performed. Heterogeneity was assessed using I² statistics, and publication bias was evaluated through funnel plot analysis and Egger’s regression test.

    Results Ten studies were included, involving 79 patients (55.7% male) with 79 AVMs (54.4% unruptured and 70.9% Spetzler–Martin grade III-V) who underwent 123 embolizations (80.4% and 5.9% under transarterial and transvenous approaches, respectively) with n-butyl cyanoacrylate (80.4%), ethylene vinyl alcohol (14.4%), or both (5.2%). The incidence of transient adenosine-related intraoperative complications was 0% (95% CI 0% to 3%, I2=24%). Besides, the incidence of adenosine-related morbidity, mortality, and permanent outcomes was 0% (95% CI 0% to 3%, I2=0%). During follow-up, good functional outcomes were reported for 64 patients (81%).

    Conclusions Adenosine’s effects on blood flow control can facilitate embolization and mitigate the risk of AVM rupture and embolic agent migration. Although current evidence stems from observational studies, the results of this meta-analysis suggest a safe drug profile due to minimal associated morbidity and mortality. Further research from larger randomized and controlled studies is warranted to attain a higher level of evidence.

    PROSPERO registry number CRD42023494116

    • Arteriovenous Malformation
    • Embolic
    • Liquid Embolic Material
    • Blood Flow
    • Hemorrhage

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    • X @JhonBocanegraB1, @filipi_andreao, @OliveiraLB_MD, @FerreiraMY_MD, @rbertani_neuro, @DrLopezGonzalez

    • Contributors Concept and design: JEBB. Selection of articles: MERP, ETPW. Acquisition of data: JEBB, AP, KK. Analysis and interpretation of data: JEBB, FFA, JLAS, MYF, RB. Manuscript writing and revision: JEBB, LBO, KA, FFA, MYF, MALG, JLAS. Study supervision: MALG, JEBB, RB, JLAS. Study's guarantor: JEBB.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.