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Musmar B, Adeeb N, Abdalrazeq H, Salim HA, Roy JM, Aslan A, Tjoumakaris SI, Ogilvy CS, Baskaya MK, Kondziolka D, Sheehan J, Riina H, Kandregula S, Dmytriw AA, Abushehab A, El Naamani K, Abdelsalam A, Ironside N, Kumbhare D, Gummadi S, Ataoglu C, Essibayi MA, Keles A, Muram S, Sconzo D, Rezai A, Alwakaa O, Tos SM, Mantziaris G, Park MS, Hanalioglu S, Erginoglu U, Pöppe J, Sen RD, Griessenauer CJ, Burkhardt JK, Starke RM, Sekhar LN, Levitt MR, Altschul DJ, Haranhalli N, McAvoy M, Zeineddine HA, Abla AA, Atallah E, Gooch MR, Rosenwasser RH, Stapleton C, Koch M, Srinivasan VM, Chen PR, Blackburn S, Bulsara K, Kim LJ, Choudhri O, Pukenas B, Smith E, Mosimann PJ, Alaraj A, Aziz-Sultan MA, Patel AB, Savardekar A, Notarianni C, Cuellar HH, Lawton M, Guthikonda B, Morcos J, Jabbour P. Comparative outcomes of arteriovenous malformations treatment in eloquent versus non-eloquent brain: A multicenter study with propensity-score weighting. Int J Stroke 2025:17474930251323503. [PMID: 39948730 DOI: 10.1177/17474930251323503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2025]
Abstract
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 1013 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.
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Affiliation(s)
- Basel Musmar
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nimer Adeeb
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Hammam Abdalrazeq
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Hamza Adel Salim
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | - Joanna M Roy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Assala Aslan
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
| | | | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Howard Riina
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Sanjeev Gummadi
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Cagdas Ataoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Muhammed Amir Essibayi
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Abdullah Keles
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Sandeep Muram
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Sconzo
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arwin Rezai
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Omar Alwakaa
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Salem M Tos
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Georgios Mantziaris
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Sahin Hanalioglu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ufuk Erginoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Johannes Pöppe
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Rajeev D Sen
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Starke
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laligam N Sekhar
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - David J Altschul
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Neil Haranhalli
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Malia McAvoy
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Hussein A Zeineddine
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Adib A Abla
- Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Peng R Chen
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ketan Bulsara
- Department of Neurosurgery, University of Connecticut, Mansfield, CT, USA
| | - Louis J Kim
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Omar Choudhri
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Bryan Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Smith
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal J Mosimann
- Division of Interventional and Diagnostic Neuroradiology, Department of Radiology, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois Chicago, Chicago, IL, USA
| | - Mohammad A Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amey Savardekar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Christina Notarianni
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Hugo H Cuellar
- Department of Radiology, Louisiana State University, Shreveport, LA, USA
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Michael Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, LA, USA
| | - Jacques Morcos
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Flores-Milan G, Rainone GJ, Peto I, Vakharia KV, Guerrero WR, Mokin M, Hartnett SM, Agazzi S. Timing of Embolization, Radiosurgery, and Resection of Arteriovenous Malformations in Pediatric Patients: A Retrospective, Descriptive Study. World Neurosurg 2024; 190:e488-e495. [PMID: 39074586 DOI: 10.1016/j.wneu.2024.07.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Cerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization, and stereotactic radiosurgery. There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/stereotactic radiosurgery and resection is not well explored in the literature. We present a series of pediatric patients with AVMs, with special attention directed to the timing of treatment. METHODS Electronic medical records of all pediatric patients (<18 years old at treatment) with AVMs treated at our institution were retrospectively reviewed after institutional review board approval. Demographic information, AVM characteristics, treatment variables, and outcomes were recorded. RESULTS In our cohort of 27 patients, 21 (77.8%) presented with a ruptured AVM. Of these patients, 6 (28.6%) had a Glasgow Coma Scale score of 3-10 and underwent treatment within 24 hours of presentation, and 10 (47.6%) with a Glasgow Coma Scale score of 12-15 were treated between 24 and 120 hours after presentation. The remaining 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. Regardless of rupture status, 96% of our cohort had a modified Rankin Scale score of 1-2 at most recent follow-up. CONCLUSIONS We present our institution's experience with pediatric AVMs, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status.
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Affiliation(s)
- Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Gersham J Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Kunal V Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Waldo R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Sara M Hartnett
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
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