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Pinheiro LCP, Wolak Junior M, Ferreira MY, Magalhaes RB, Fernandes AY, Paiva WS, Zanini MA, Marchesan Rodrigues MA. Unruptured Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis of Mortality and Morbidity in Aruba-Eligible Studies. World Neurosurg 2024; 185:381-392.e1. [PMID: 38423455 DOI: 10.1016/j.wneu.2024.02.109] [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: 01/02/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies. METHODS Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities. RESULTS Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%. CONCLUSIONS The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.
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Quan K, Qin X, Song J, Zhu W. How we do it? The surgical resection of a medial parietal arteriovenous malformation under multimodal imaging technology-guided hybrid operation. Acta Neurochir (Wien) 2023; 165:3787-3791. [PMID: 37845355 DOI: 10.1007/s00701-023-05836-8] [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: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND This report described the surgical resection of a challenging medial parietal lobe arteriovenous malformation (AVM) using the hybrid operation theater with a multimodal imaging-guided technology. METHOD A 29-year-old male was admitted to treat a ruptured medial parietal AVM. The deep and diffusive compartment of the nidus was embolized before resection. Preoperatively and intraoperatively, mixed reality technology with multimodality imaging was utilized for surgical planning and navigation. The nidus was totally resected and confirmed by intraoperative angiography. The patient recovered without sequella. CONCLUSION We hope this report provides new insights into applying multimodal imaging technology-guided hybrid operation for brain AVM.
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Affiliation(s)
- Kai Quan
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China
| | - Xuanfeng Qin
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China
| | - Jianping Song
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China.
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China.
- Department of Neurosurgery, National Regional Medical Center, Huashan Hospital Fujian Campus, Fudan University, Fuzhou, 350209, Fujian, China.
| | - Wei Zhu
- Department of Neurosurgery, National Center for Neurological Disorders, Huashan Hospital, Fudan University, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, 200040, China
- Research Unit of New Technologies of Micro-Endoscopy Combination in Skull Base Surgery (2018RU008), Chinese Academy of Medical Sciences (CAMS), Shanghai, 200040, China
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3
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Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations. World Neurosurg 2023; 172:e611-e624. [PMID: 36738962 DOI: 10.1016/j.wneu.2023.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients. METHODS The first randomized clinical trial (RCT-1) offers 1:1 randomized allocation of intervention versus conservative management for patients with arteriovenous malformation (AVM). The second randomized clinical trial (RCT-2) allocates 1:1 pre-embolization or no pre-embolization to surgery or radiosurgery patients judged treatable with or without embolization. Characteristics of RCT patients are reported and compared to registry patients. RESULTS From June 2014 to May 2021, 1010 patients with AVM were recruited; 498 patients were observed and 373 were included in the treatment registries. Randomized allocation in RCT-1 was applied to 139 (26%) of the 512 patients (including 127 of 222 [57%] with unruptured AVMs) considered for curative treatment. RCT-1 AVM patients differed (in rupture status, Spetzler-Martin grade and baseline modified Rankin Score) from those in the observation or treatment registries (P < 0.001). Most patients had small (<3 cm; 71%) low-grade (Spetzler-Martin I-II; 64%) unruptured (91%) AVMs. The allocated management was conservative (n = 71) or curative (n = 68), using surgery (n = 39), embolization (n = 16), or stereotactic radiosurgery (n = 13). Pre-embolization was considered for 179/309 (58%) patients allocated/assigned to surgery or stereotactic radiosurgery; 87/179 (49%) were included in RCT-2. RCT-2 patient AVMs differed in size, eloquence and grade from patients of the pre-embolization registry (P < 0.01). Most had small (<3 cm in 82%) low-grade (83%) AVMs in non-eloquent brain (64%). CONCLUSIONS Patients included in the RCTs differ significantly from registry patients. Meaningful results can be obtained if multiple centers actively participate in the TOBAS RCTs.
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Muacevic A, Adler JR. Management of Brain Arteriovenous Malformations: A Review. Cureus 2023; 15:e34053. [PMID: 36824547 PMCID: PMC9942537 DOI: 10.7759/cureus.34053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/23/2023] Open
Abstract
Brain arteriovenous malformations (bAVM) are vascular malformations of the brain affecting all ages. The optimum management strategy is essentially devoid of high-quality evidence and is highly nuanced and embedded in local customs. This study summarizes the frequently employed management strategies, drawing conclusions on the utility of each method of treatment and delving into controversies surrounding them. A literature search on PubMed and Medline was done on January 3rd, 2022. 11,767 articles were found, and abstracts were reviewed. Full-text review of 153 articles led to chapters from three books and 71 articles incorporated into a summative discussion. Spetzler-Ponce (S-P) Class A patients may be offered surgery if they are good surgical candidates and have a good number of high-quality years of life left. The exception is diffuse Spetzler-Martin (S-M) grade 2 in a patient older than 40 years: radiosurgery for unruptured and embolization for ruptured. S-P Class B may be offered surgery if a compact nidus or if younger than 40 years. If diffuse or age greater than 40, radiosurgery may be preferred if the Pollock-Flickinger score is less than 2.5. For the remainder of S-P Class B, conservative management may be preferred. S-P Class C is generally not treated unless young or those patients with poorly controlled seizures affecting their quality of life are willing to risk permanent neurological deficits. While the quality of studies is generally high, the level of evidence is concerning with only one randomized controlled trial (RCT). Most research output hails from high-income countries, i.e., perhaps not universally applicable to all settings owing to possible genetic, environmental, and resource differences. More research is needed: large volume studies in the pregnant population, validation of scoring systems in pediatric age groups, clinical trials focused on combination multi-staged treatment modalities, and studies originating from the developing world.
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Darsaut TE, Magro E, Bojanowski MW, Chaalala C, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Sabatier JF, Cognard C, Januel AC, Pelissou-Guyotat I, Eker O, Roche PH, Graillon T, Brunel H, Proust F, Beaujeux R, Aldea S, Piotin M, Cornu P, Shotar E, Gaberel T, Barbier C, Corre ML, Costalat V, Jecko V, Barreau X, Morandi X, Gauvrit JY, Derrey S, Papagiannaki C, Nguyen TN, Abdalkader M, Tawk RG, Huynh T, Viard G, Gevry G, Gentric JC, Raymond J. Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:891-899. [PMID: 36087316 DOI: 10.3171/2022.7.jns22813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).
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Affiliation(s)
- Tim E Darsaut
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Elsa Magro
- 2Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Michel W Bojanowski
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Lorena Nico
- 4Division of Interventional Neuroradiology, Department of Radiology, CHU Saint-Etienne, North Hospital, Saint-Etienne, France
| | - Emma Bacchus
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Jean-Francois Sabatier
- 7Department of Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Christophe Cognard
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Anne-Christine Januel
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | | | - Omer Eker
- 10Diagnostic and Interventional Neurological Imaging, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Thomas Graillon
- 12Department of Neurosurgery, Aix Marseille University, INSERM, AP-HM, MMG, UMR1251, Marmara Institute, La Timone Hospital, Marseille, France
| | - Hervé Brunel
- 13Department of Neuroradiology, La Timone Hospital, AP-HM, Marseille, France
| | - Francois Proust
- 14Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- 15Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France
| | | | - Michel Piotin
- 17Interventional Radiology, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - Eimad Shotar
- 19Neuroradiology, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | - Charlotte Barbier
- 21Vascular and Interventional Imaging, CHU Caen Normandie, Caen, France
| | | | | | - Vincent Jecko
- 24Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- 25Diagnostic and Therapeutic Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | | | - Jean-Yves Gauvrit
- 27Neuroradiology, Pontchaillou Hospital, Rennes University Hospital, Rennes, France
| | | | | | - Thanh N Nguyen
- Departments of30Radiology.,31Neurology, and.,32Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Thien Huynh
- 34Radiology, Mayo Clinic, Jacksonville, Florida
| | - Geraldine Viard
- 35Clinical Investigation Center, CHU Brest, Brest, France; and
| | - Guylaine Gevry
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- 36Department of Interventional Neuroradiology, Cavale Blanche Hospital, Brest University Hospital, Brest, France
| | - Jean Raymond
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada.,6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
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Nguyen BT, Huynh CT, Nguyen TM, Nguyen VT, Karras CL, Huynh-Le P, Tran HM. Gamma Knife radiosurgery for brain arteriovenous malformations: a 15-year single-center experience in Southern Vietnam. World Neurosurg 2022; 163:71-79. [DOI: 10.1016/j.wneu.2022.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
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Acute spontaneous subdural hematoma secondary to ruptured arteriovenous malformation: A rare entity. Ann Med Surg (Lond) 2021; 68:102613. [PMID: 34381601 PMCID: PMC8340043 DOI: 10.1016/j.amsu.2021.102613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Acute spontaneous subdural hematoma (ASSDH) due to ruptured arteriovenous malformation (AVM) is exceptional. There were only four reported cases. In this paper, we present a successful multimodality treatment of the ASSDH secondary to ruptured AVM. Case presentation A 21-year-old healthy man with no history of trauma presented to our hospital with complaints of severe headache for 12 hours before admission. On examination, he was alert and oriented. He had no intracranial hypertension, meningismus, and neurological deficits. Computed tomography illustrated a right acute subdural hematoma 8mm in thickness with a 5mm midline shift and a right frontal intraparenchymal hemorrhage 40 × 25mm in size. Digital subtraction angiography showed a 2 × 3 cm right frontal AVM, Spetzler-Martin grade I. The feeding arteries were cortical branches of the right anterior cerebral artery, and drain veins were cortical veins. He received emergency preoperative embolization followed by hematoma evacuation and total excision of the malformation. His headache was relieved and disappeared after a week. No postoperative neurological deficits were reported. Clinical discussion Elective surgical resection of AVM after 4–6 weeks was preferred in patients with no risk factors of rebleeding. Emergent surgery was only indicated for significant mass effect or acute hydrocephalus. Preoperative embolization is helpful for the presence of intra-nidal or peri-nidal aneurysm, AVM with high grades, reducing intraoperative blood loss and occlusion of deep vessels. Conclusion ASSDH due to ruptured AVM is rare and easy to omit in clinical settings. Preoperative embolization and surgical excision are effective treatments. Acute spontaneous SDH due to ruptured AVM is quite rare and easy to omit in clinical settings. Prompt CTA or MRA should be considered initial screening tools when available to rule out a ruptured AVM. Preoperative embolization and surgical excision are the mainstays of treatment of ruptured AVMs.
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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9
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Grüter BE, Sun W, Fierstra J, Regli L, Germans MR. Systematic review of brain arteriovenous malformation grading systems evaluating microsurgical treatment recommendation. Neurosurg Rev 2021; 44:2571-2582. [PMID: 33501562 PMCID: PMC8490254 DOI: 10.1007/s10143-020-01464-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/30/2020] [Accepted: 12/15/2020] [Indexed: 01/07/2023]
Abstract
When evaluating brain arteriovenous malformations (bAVMs) for microsurgical resection, the natural history of bAVM rupture must be balanced against the perioperative risks. It is therefore adamant to have a reliable surgical grading system, balancing these important factors. This study systematically reviews the literature in order to identify and assess the quality of grading systems with regard to microsurgical bAVM treatment. A systematic literature review was performed to provide an overview of all available bAVM grading systems relevant for microsurgical treatment evaluation and to assess the most comprehensive grading system specifically for each subgroup of bAVM (i.e., unruptured, ruptured, and posterior fossa). Screening of 865 papers revealed thirteen grading systems for bAVM microsurgical risk stratification. Among them, two systems were specifically developed for ruptured bAVM and one specifically for posterior fossa bAVM. With one system being fundamentally different for supratentorial bAVM, the remaining nine systems used the same parameters: “size,” “eloquence,” “venous drainage,” “arterial feeders,” “age,” “nidus compactness,” and “hemorrhagic presentation”. This study provides a comprehensive overview of all available bAVM grading systems relevant for surgical risk stratification. Furthermore, in the absence of a universal system appropriate to score all bAVMs, a workflow for selection of the best applicable scoring system in accordance with bAVM subgroups is presented.
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Affiliation(s)
- Basil E Grüter
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, 10, 8091, Zurich, Switzerland.
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.
| | - Wenhua Sun
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, 10, 8091, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, 10, 8091, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, 10, 8091, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, 10, 8091, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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10
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Brain Arteriovenous Malformations: Impact of Neurologic Status, Bleeding, and Type of Treatment on Final Outcome. J Neurol Surg A Cent Eur Neurosurg 2020; 82:130-137. [PMID: 33291154 DOI: 10.1055/s-0040-1714659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Well-designed studies assessing the treatment outcome of brain arteriovenous malformations (AVMs) are infrequent and have not consistently included all of the available treatment modalities, making their results not completely generalizable. Moreover, the predictors of poor outcome are not well defined. METHODS We performed an observational retrospective study of AVM patients. We included patients with clinical, radiologic, and outcome data, with a minimum follow-up of 1 year. Neurologic outcome was documented using the modified Rankin Scale (mRS) at the AVM diagnosis and 30 days after the treatment. RESULTS There were 117 patients, with equal male/female proportion. The mean follow-up time was 51 months. Treatment distribution in the Spetzler-Martin grades I-III was as follows: 52 (54.6%) surgery, 31 (32.35%) radiosurgery, 2 (0.02%) embolization, and 11 (12%) conservative follow-up. Treatment distribution in Spetzler-Martin grades IV and V was as follows: 4 (20%) surgery, 7 (35%) radiosurgery, and 10 (45%) conservative follow-up. Poor neurologic outcome (mRS ≥ 3) was significantly associated with poor clinical status at diagnosis (Glasgow Coma Scale [GCS] score< 14; odds ratio [OR]: 0.20; 95% confidence interval [CI]: 0.001-0.396; p = 0.010). The rupture of the AVM was associated with poor neurologic outcome. The Lawton-Young Supplementary scale (LYSS) proved to be the most effective in predicting poor outcome. The existence of seizures, treatment-related complications, and conservative treatment was associated with the worsening of the mRS score, whereas the existence of hemorrhage was associated with the likelihood of disability. CONCLUSION Our results suggest that poor neurologic status at diagnosis, AVM rupture, and conservative treatment were associated with worse outcome. Hemorrhage as initial presentation is related to disability, not with mRS worsening. The LYSS appeared to be the best method to predict outcome.
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11
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Kawashima M, Hasegawa H, Shin M, Shinya Y, Ishikawa O, Koizumi S, Katano A, Nakatomi H, Saito N. Outcomes of stereotactic radiosurgery for hemorrhagic arteriovenous malformations with or without prior resection or embolization. J Neurosurg 2020; 135:733-741. [PMID: 33276336 DOI: 10.3171/2020.7.jns201502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The major concern about ruptured arteriovenous malformations (rAVMs) is recurrent hemorrhage, which tends to preclude stereotactic radiosurgery (SRS) as a therapeutic modality for these brain malformations. In this study, the authors aimed to clarify the role of SRS for rAVM as a stand-alone modality and an adjunct for a remnant nidus after surgery or embolization. METHODS Data on 410 consecutive patients with rAVMs treated with SRS were analyzed. The patients were classified into groups, according to prior interventions: SRS-alone, surgery and SRS (Surg-SRS), and embolization and SRS (Embol-SRS) groups. The outcomes of the SRS-alone group were analyzed in comparison with those of the other two groups. RESULTS The obliteration rate was higher in the Surg-SRS group than in the SRS-alone group (5-year cumulative rate 97% vs 79%, p < 0.001), whereas no significant difference was observed between the Embol-SRS and SRS-alone groups. Prior resection (HR 1.78, 95% CI 1.30-2.43, p < 0.001), a maximum AVM diameter ≤ 20 mm (HR 1.81, 95% CI 1.43-2.30, p < 0.001), and a prescription dose ≥ 20 Gy (HR 2.04, 95% CI 1.28-3.27, p = 0.003) were associated with a better obliteration rate, as demonstrated by multivariate Cox proportional hazards analyses. In the SRS-alone group, the annual post-SRS hemorrhage rates were 1.5% within 5 years and 0.2% thereafter and the 10-year significant neurological event-free rate was 95%; no intergroup difference was observed in either outcome. The exclusive performance of SRS (SRS alone) was not a risk for post-SRS hemorrhage or for significant neurological events based on multivariate analyses. These results were also confirmed with propensity score-matched analyses. CONCLUSIONS The treatment strategy for rAVMs should be tailored with due consideration of multiple factors associated with the patients. Stand-alone SRS is effective for hemorrhagic AVMs, and the risk of post-SRS hemorrhage was low. SRS can also be favorably used for residual AVMs after initial interventions, especially after failed resection.
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Affiliation(s)
| | - Hirotaka Hasegawa
- Departments of1Neurosurgery and
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Atsuto Katano
- 3Radiology, University of Tokyo Hospital, Tokyo, Japan; and
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Chen CJ, Ding D, Derdeyn CP, Lanzino G, Friedlander RM, Southerland AM, Lawton MT, Sheehan JP. Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions. Neurology 2020; 95:917-927. [PMID: 33004601 DOI: 10.1212/wnl.0000000000010968] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.
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Affiliation(s)
- Ching-Jen Chen
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Dale Ding
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Giuseppe Lanzino
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Robert M Friedlander
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Andrew M Southerland
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Jason P Sheehan
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
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Patel NJ, Bervini D, Eftekhar B, Davidson AS, Walsh DC, Assaad NN, Morgan MK. Results of Surgery for Low-Grade Brain Arteriovenous Malformation Resection by Early Career Neurosurgeons: An Observational Study. Neurosurgery 2020; 84:655-661. [PMID: 29608734 DOI: 10.1093/neuros/nyy088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 02/22/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND For sustainability of arteriovenous malformation (AVM) surgery, results from early career cerebrovascular neurosurgeons (ECCNs) must be acceptably safe. OBJECTIVE To determine whether ECCNs performance of Spetzler-Ponce Class A AVM (SPC A) resection can be acceptably safe. METHODS ECCNs completing a cerebrovascular fellowship (2004-2015) with the last author were included. Inclusion of the ECCN cases occurred if they: had a prospective database of all AVM cases since commencing independent practice; were the primary surgeon on SPC A; and had made the significant management decisions. All SPC A surgical cases from the beginning of the ECCN's independent surgical practice to a maximum of 8 yr were included. An adverse outcome was considered a complication of surgery leading to a new permanent neurological deficit with a last modified Rankin Scale score >1. A cumulative summation (Cusum) plot examined the performance of each surgery. The highest acceptable level of adverse outcomes for the Cusum was 3.3%, derived from the upper 95% confidence interval of the last author's reported series. RESULTS Six ECCNs contributed 110 cases for analysis. The median number of SPC A cases operated by each ECCN was 16.5 (range 4-40). Preoperative embolization was performed in 5 (4.5%). The incidence of adverse outcomes was 1.8% (95% confidence interval: <0.01%-6.8%). At no point during the accumulated series did the combined cohort become unacceptable by the Cusum plot. CONCLUSION ECCNs with appropriate training appointed to large-volume cerebrovascular centers can achieve results for surgery for SPC A that are not appreciably worse than those published from high-volume neurosurgeons.
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Affiliation(s)
- Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - David Bervini
- Department of Neurosurgery, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Behzad Eftekhar
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia.,Department of Neurosurgery, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Andrew Stewart Davidson
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia.,Department of Neurosurgery, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Daniel C Walsh
- Department of Neurosurgery, Kings College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom.,Department of Clinical Neuroscience, Institute of Psychiatry, King's College London, 1st floor, Maurice Wohl Clinical Neuroscience Institute, London, United Kingdom
| | - Nazih N Assaad
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia.,Department of Neurosurgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael Kerin Morgan
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia
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14
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Ishikawa O, Nakatomi H, Saito N. Re-Evaluation of the Size Limitation in Single-Session Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Detailed Analyses on the Outcomes with Focusing on Radiosurgical Doses. Neurosurgery 2019; 86:685-696. [DOI: 10.1093/neuros/nyz280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 04/16/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Single-session stereotactic radiosurgery (SRS) for large arteriovenous malformations (AVMs) ≥10 mL remains controversial, which is considered as the current size limitation.
OBJECTIVE
To reconsider the size limitation of SRS for AVMs by profoundly analyzing dose-volume relationship.
METHODS
Data on 610 consecutive patients with AVM treated with SRS using regular (18-22 Gy) or low (<18 Gy) prescription doses were retrospectively analyzed. AVMs were classified into 4 groups: small (<5 mL), medium (≥5 and <10 mL), medium-large (≥10 and <15 mL), and large (≥15 mL). The maximum volumes were 22.5 mL (regular-dose group) and 23.5 mL (low-dose group).
RESULTS
When treated with regular doses, the cumulative 6-yr obliteration rates for each of the 4 AVM groups were 86%, 80%, 87%, and 79%, respectively; the cumulative 10-yr significant neurological event (SNE) rates were 2.6%, 3.9%, 6.8%, and 5.3%, respectively. Regarding large AVMs, regular-dose SRS resulted in marginally better obliteration rate (6-yr cumulative rate, 79% vs 48%, P = .111) and significantly lower SNE (5-yr cumulative rate, 5% vs 31%, P = .038) and post-SRS hemorrhage rate (8-yr cumulative rate, 0% vs 54%, P = .002) compared to low-dose SRS. Multivariate analyses revealed that regular-dose SRS significantly contributed to increase in the obliteration rate and decrease in SNEs and hemorrhage.
CONCLUSION
The outcomes for large AVMs were generally favorable when treated with ablative doses. Single-session SRS could be acceptable for AVMs up to ≈20 mL if treated with ablative doses.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Shunya Hanakita
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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15
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Bazarde HA, Wenz F, Hänggi D, Etminan N. Radiosurgery of Brain Arteriovenous and Cavernous Malformations. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_10-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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16
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Kocer N, Kandemirli SG, Dashti R, Kizilkilic O, Hanimoglu H, Sanus GZ, Tunali Y, Tureci E, Islak C, Kaynar MY. Single-stage planning for total cure of grade III-V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection. Neuroradiology 2018; 61:195-205. [PMID: 30488257 DOI: 10.1007/s00234-018-2140-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE There are no established guidelines for treatment of Spetzler-Martin grade III-V brain arteriovenous malformations (bAVMs). The purpose of this study is to report our institutional experience in total obliteration/eradication of grade III-V bAVMs by single-stage planning of embolization combined with microsurgical resection when necessary. METHODS All patients harboring Spetzler-Martin (S-M) grade III-V bAVMs treated with single-stage planning between January 2006 and January 2018 were retrospectively reviewed. This treatment paradigm is applicable only to surgically accessible bAVMs and does not include deep-seated bAVMs. Indications for treatment, clinical presentation, imaging characteristics, and treatment outcomes were analyzed. Outcomes were assessed based on modified Rankin Scale. RESULTS A total of 31 patients were identified. Seventeen patients (54.8%) presented with hemorrhage, 10 (32.3%) with seizures, 3 (9.7%) with headaches, and 1 (3.2%) with progressive neurological deficit. Based on S-M grading system, 25 patients (80.6%) harbored grade III bAVM, 5 patients had grade IV bAVMs (16.1%), and 1 patient (3.2%) had a grade V bAVM. There were no treatment-related complications in 24/31 (77.4%) patients. Of the total of seven patients with complications, four patients had clinical deterioration. The long-term (> 6-month), non-disabling morbidity (mRS ≤ 2) rate was 6.5%. The long-term, disabling morbidity rate was 3.2% with a mortality of 3.2%. Complete angiographic obliteration was achieved in 30/31 (96.8%) patients. CONCLUSION Single-stage treatment strategy can be considered as an alternative to multistage embolization prior to surgery in grade III-V bAVMs. In this study, a high rate of total obliteration with relatively low rates of permanent morbidity and mortality was achieved.
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Affiliation(s)
- Naci Kocer
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey.
| | - Sedat Giray Kandemirli
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Reza Dashti
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Osman Kizilkilic
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Hakan Hanimoglu
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yusuf Tunali
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ercan Tureci
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Mehmet Yasar Kaynar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Jiao Y, Wu J, Chen X, Li Z, Ma J, Cao Y, Wang S. Spetzler-Martin grade IV and V arteriovenous malformations: Treatment outcomes and risk factors for negative outcomes after surgical resection. J Clin Neurosci 2018; 61:166-173. [PMID: 30448296 DOI: 10.1016/j.jocn.2018.10.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Microsurgical resection may be recommended for high grade brain arteriovenous malformations (BAVMs) (HBAVMs) in individualized patients. Careful case selection is necessary to minimize postoperative complications. The aim of this study was to determine the surgical outcomes in patients with HBAVMs and to identify their risk factors associated with postoperative negative outcomes. PATIENTS AND METHODS We retrospectively studied 53 consecutive patients with HBAVMs. All patients had undergone preoperative diffusion tensor imaging (DTI), MRI, 3D time-of-flight MRA (3D TOF-MRA) and digital subtraction angiography (DSA) followed by resection. White matter (WM) eloquent fibre tracts, including the corticospinal tract (CST), optic radiation (OR) and arcuate fasciculus (AF), were tract. Both functional, angioarchitectural and operative factors were analyzed with respect to the surgical outcomes. RESULTS Nineteen (35.8%) patients suffered from negative surgical outcomes (MRS > 2) one week after surgery. At the last clinic visit, 10 patients (18.9%) suffered from negative surgical outcomes. Diffuse nidus (P = 0.018), Perforating arteries (PA) supplying (P = 0.009) and CST involving (P = 0.001) were independent risk factors for negative short-term outcomes. PA supplying (P = 0.039), CST involving (P = 0.026) and postoperative intracranial haemorrhage (ICH) (P = 0.014) were independent risk factors for negative long-term neurological outcomes. Larger nidus size (P = 0.024) was predictor of postoperative ICH. The cut-off point was 6.8 cm. CONCLUSIONS This study identified that diffuse nidus, PA supplying and CST involving are risk factors for negative short-term outcomes in patients with HBAVMs. PA supplying, CST involving and postoperative ICH are risk factors for negative long-term outcomes. Larger nidus size was risk factor for postoperative ICH.
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Affiliation(s)
- Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China.
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China
| | - Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China
| | - Zhicen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China
| | - Ji Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, PR China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, PR China
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Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation. Neurochirurgie 2018; 64:316-320. [PMID: 29908698 DOI: 10.1016/j.neuchi.2018.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/20/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.
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Hasegawa H, Hanakita S, Shin M, Kawashima M, Takahashi W, Ishikawa O, Koizumi S, Nakatomi H, Saito N. Comparison of the Long-term Efficacy and Safety of Gamma Knife Radiosurgery for Arteriovenous Malformations in Pediatric and Adult Patients. Neurol Med Chir (Tokyo) 2018; 58:231-239. [PMID: 29769453 PMCID: PMC6002683 DOI: 10.2176/nmc.st.2018-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is debated whether the efficacy and long-term safety of gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs) differs between adult and pediatric patients. We aimed to clarify the long-term outcomes of GKRS in pediatric patients and how they compare to those in adult patients. We collected data for 736 consecutive patients with AVMs treated with GKRS between 1990 and 2014 and divided the patients into pediatric (age < 20 years, n = 144) and adult (age ≥ 20 years, n = 592) cohorts. The mean follow-up period in the pediatric cohort was 130 months. Compared to the adult patients, the pediatric patients were significantly more likely to have a history of hemorrhage (P < 0.001). The actuarial rates of post-GKRS nidus obliteration in the pediatric cohort were 36%, 60%, and 87% at 2, 3, and 6 years, respectively. Nidus obliteration occurred earlier in the pediatric cohort than in the adult cohort (P = 0.015). The actuarial rates of post-GKRS hemorrhage in the pediatric cohort were 0.7%, 2.5%, and 2.5% at 1, 5, and 10 years, respectively. Post-GKRS hemorrhage was marginally less common in the pediatric cohort than in the adult cohort (P = 0.056). Cyst formation/encapsulated hematoma were detected in seven pediatric patients (4.9%) at a median post-GKRS timepoint of 111 months, which was not significantly different from the rate in the adult cohort. Compared to adult patients, pediatric patients experience earlier therapeutic effects from GKRS for AVMs, and this improves long-term outcomes.
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Affiliation(s)
| | | | - Masahiro Shin
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Osamu Ishikawa
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Nobuhito Saito
- Department of Neurosurgery, University of Tokyo Hospital
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Morgan MK, Guilfoyle M, Kirollos R, Heller GZ. Remodeling of the Feeding Arterial System After Surgery for Resection of Brain Arteriovenous Malformations: An Observational Study. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Kerin Morgan
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia
| | - Mathew Guilfoyle
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Ramez Kirollos
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Gillian Z Heller
- Department of Statistics, Macquarie University, New South Wales, Australia
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The impact of nTMS mapping on treatment of brain AVMs. Acta Neurochir (Wien) 2018; 160:567-578. [PMID: 29368047 DOI: 10.1007/s00701-018-3475-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/16/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The treatment of brain arteriovenous malformations (BAVMs) is still contrarily discussed. Despite the debatable results of the ARUBA trial, most BAVMs still require treatment depending on the Spetzler-Martin (SM) grading. Since size is measurable and venous drainage is visible, the determination of eloquence is comparably crucial but not fully objective. The present bicentric cohort study aims to examine the influence of preoperative navigated transcranial magnetic stimulation (nTMS) motor and language mapping data on decision-making for or against surgical treatment of BAVMs. METHODS The influence of data from nTMS on decision-making for or against treatment of BAVMs was examined by confirming/falsifying presumed motor or language eloquence. RESULTS The results of nTMS mappings changed the SM grading in nine cases. In six cases, the SM grading changed to a lower grade (= falsified eloquence); in three cases, the SM grading changed to a higher grade due to nTMS mappings (= unexpected eloquence). Out of all 34 cases, indication for surgery was supported by nTMS mappings in 15 cases (7 motors, 8 languages). In six cases, the decision against surgery was made based on nTMS mappings (three motors, three languages). CONCLUSION In 21 of 34 cases (62%), nTMS was a supportive argument. We could show that nTMS motor and language data can be used for a more objective decision-making regarding the treatment of BAVMs and for a more detailed SM grading regarding the rating of eloquence.
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Morgan MK, Wiedmann MKH, Assaad NNA, Parr MJA, Heller GZ. Deliberate employment of postoperative hypotension for brain arteriovenous malformation surgery and the incidence of delayed postoperative hemorrhage: a prospective cohort study. J Neurosurg 2017; 127:1025-1040. [DOI: 10.3171/2016.9.jns161333] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to examine the impact of deliberate employment of postoperative hypotension on delayed postoperative hemorrhage (DPH) for all Spetzler-Ponce Class (SPC) C brain arteriovenous malformations (bAVMs) and SPC B bAVMs ≥ 3.5 cm in diameter (SPC B 3.5+).METHODSA protocol of deliberate employment of postoperative hypotension was introduced in June 1997 for all SPC C and SPC B 3.5+ bAVMs. The aim was to achieve a maximum mean arterial blood pressure (BP) ≤ 70 mm Hg (with cerebral perfusion pressure > 50 mm Hg) for a minimum of 7 days after resection of bAVMs (BP protocol). The authors compared patients who experienced DPH (defined as brain hemorrhage into the resection bed that resulted in a new neurological deficit or that resulted in reoperation during the hospitalization for microsurgical bAVM resection) between 2 periods (prior to adopting the BP protocol and after introduction of the BP protocol) and 4 bAVM categories (SPC A, SPC B 3.5− [that is, SPC B < 3.5 cm maximum diameter], SPC B 3.5+, and SPC C). Patients excluded from treatment by the BP protocol were managed in the intensive care unit to avoid moderate hypertensive episodes. The pooled cases of all bAVM treated by surgery were analyzed to identify characteristics associated with the risk of DPH. These identified characteristics were then examined by multiple logistic regression analysis in both SPC B 3.5+ and SPC C cases.RESULTSFrom a cohort of 641 bAVMs treated by microsurgery, 32 patients with DPH were identified. Of those, 66% (95% CI 48–80) had a permanent new neurological deficit with a modified Rankin Scale score of 2–6. This included a mortality rate of 13% (95% CI 4.4–29). The BP protocol was used to treat 162 patients with either SPC B 3.5+ or SPC C. For SPC B 3.5+, there was no significant reduction in DPH with the introduction of the BP protocol (p = 0.77). For SPC C, there was a significant (p = 0.035) reduction of DPH from 29% (95% CI 13%–53%) to 8.2% (95% CI 3.2%–18%) associated with the introduction of the BP protocol. Multiple logistic regression analysis found that the absence of the BP protocol (p = 0.011, odds ratio 7.5, 95% CI 1.6–36) remained significant for the development of DPH in patients with SPC C bAVMs.CONCLUSIONSTreating patients with SPC C bAVMs with a protocol that lowers BP immediately after resection seems to reduce the risk of DPH. For SPC A and SPC B 3.5− bAVMs, there is unlikely to be a need to do more than avoid postoperative hypertension. For SPC B 3.5+ bAVMs, a larger number of patients would be required to test the absence of benefit of the BP protocol.
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Affiliation(s)
| | | | | | - Michael J. A. Parr
- Departments of 1Clinical Medicine and
- 3Department of Intensive Care, Macquarie University Hospital, Ryde, New South Wales, Australia
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Nomoto AK, Shojima M, Nakatomi H, Saito N. Does Advanced Age Affect the Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformation? World Neurosurg 2017; 109:e715-e723. [PMID: 29066317 DOI: 10.1016/j.wneu.2017.10.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is generally considered a minimally invasive treatment modality. However, definitive evidence of the efficacy of SRS in the elderly population is still not available. METHODS The outcomes of 561 elderly and nonelderly patients who underwent SRS for AVM at our institution between 1990 and 2013 were reviewed, analyzed, and compared. Elderly patients were defined as those age ≥60 years at the time of SRS. RESULTS The elderly cohort comprised 55 patients; the nonelderly cohort, 506. In the elderly cohort, the median age was 65 years, and the duration of follow-up was 91 months. The actuarial obliteration rates were 47% at 3 years, 70% at 4 years, and 76% at 5 years in the elderly cohort, and 57% at 3 years, 76% at 4 years, and 83% at 5 years in the nonelderly cohort. In the elderly cohort, the hemorrhage rates during the post-SRS latent phase were 5.2%/year in patients with hemorrhagic onset and 0%/year in those with nonhemorrhagic onset, and event-free survival (EFS) was 93% at 6 years and 89% at 12 years. The obliteration rate, mortality, and EFS rate were not significantly different between the 2 cohorts, whereas the rate of perifocal edema was significantly lower (P = 0.021) in the elderly cohort. The pre-SRS and post-SRS hemorrhage rates were slightly higher in the elderly cohort, albeit without statistical significance. CONCLUSIONS Therapeutic effects and outcomes of SRS are similar in elderly and nonelderly patients. Treatment-related neurologic deficits are rare, and longer EFS can be expected.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Shunya Hanakita
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan; Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Akihiro K Nomoto
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
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Critical review of brain AVM surgery, surgical results and natural history in 2017. Acta Neurochir (Wien) 2017; 159:1457-1478. [PMID: 28555270 DOI: 10.1007/s00701-017-3217-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND An understanding of the present standing of surgery, surgical results and the role in altering the future morbidity and mortality of untreated brain arteriovenous malformations (bAVMs) is appropriate considering the myriad alternative management pathways (including radiosurgery, embolization or some combination of treatments), varying risks and selection biases that have contributed to confusion regarding management. The purpose of this review is to clarify the link between the incidence of adverse outcomes that are reported from a management pathway of either surgery or no intervention with the projected risks of surgery or no intervention. METHODS A critical review of the literature was performed on the outcomes of surgery and non-intervention for bAVM. An analysis of the biases and how these may have influenced the outcomes was included to attempt to identify reasonable estimates of risks. RESULTS In the absence of treatment, the cumulative risk of future hemorrhage is approximately 16% and 29% at 10 and 20 years after diagnosis of bAVM without hemorrhage and 35% and 45% at 10 and 20 years when presenting with hemorrhage (annualized, this risk would be approximately 1.8% for unruptured bAVMs and 4.7% for 8 years for bAVMs presenting with hemorrhage followed by the unruptured bAVM rate). The cumulative outcome of these hemorrhages depends upon whether the patient remains untreated and is allowed to have a further hemorrhage or is treated at this time. Overall, approximately 42% will develop a new permanent neurological deficit or death from a hemorrhagic event. The presence of an associated proximal intracranial aneurysm (APIA) and restriction of venous outflow may increase the risk for subsequent hemorrhage. Other risks for increased risk of hemorrhage (age, pregnancy, female) were examined, and their purported association with hemorrhage is difficult to support. Both the Spetzler-Martin grading system (and its compaction into the Spetzler-Ponce tiers) and Lawton-Young supplementary grading system are excellent in predicting the risk of surgery. The 8-year risk of unfavorable outcome from surgery (complication leading to a permanent new neurological deficit with a modified Rankin Scale score of greater than one, residual bAVM or recurrence) is dependent on bAVM size, the presence of deep venous drainage (DVD) and location in critical brain (eloquent location). For patients with bAVMs who have neither a DVD nor eloquent location, the 8-year risk for an unfavorable outcome increases with size (increasing from 1 cm to 6 cm) from 1% to 9%. For patients with bAVM who have either a DVD or eloquent location (but not both), the 8-year risk for an unfavorable outcome increases with the size (increasing from 1 cm to 6 cm) from 4% to 35%. For patients with bAVM who have both a DVD and eloquent location, the 8-year risk for unfavorable outcome increases with size (increasing from 1 cm to 3 cm) from 12% to 38%. CONCLUSION Patients with a Spetzler-Ponce A bAVM expecting a good quality of life for the next 8 years are likely to do better with surgery in expert centers than remaining untreated. Ongoing research is urgently required on the outcome of management pathways for bAVM.
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cenzato M, Boccardi E, Beghi E, Vajkoczy P, Szikora I, Motti E, Regli L, Raabe A, Eliava S, Gruber A, Meling TR, Niemela M, Pasqualin A, Golanov A, Karlsson B, Kemeny A, Liscak R, Lippitz B, Radatz M, La Camera A, Chapot R, Islak C, Spelle L, Debernardi A, Agostoni E, Revay M, Morgan MK. European consensus conference on unruptured brain AVMs treatment (Supported by EANS, ESMINT, EGKS, and SINCH). Acta Neurochir (Wien) 2017; 159:1059-1064. [PMID: 28389875 DOI: 10.1007/s00701-017-3154-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler-Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.
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Affiliation(s)
- Marco Cenzato
- Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | | | - Ettore Beghi
- Neurology, Methodologist, IRCCS Istituto Mario Negri, Milan, Italy
| | - Peter Vajkoczy
- Neurosurgery, Charitè Universitatetsmedizin, Berlin, Germany
| | - Istvan Szikora
- Neuroradiology, National Institute of NeuroScience, Budapest, Hungary
| | - Enrico Motti
- Radiosurgery, Ospedale Villa Maria di Cotignola, Ravenna, Italy
| | - Luca Regli
- Neurosurgery, UniversitaetsSpital, Zurich, Switzerland
| | | | | | - Andreas Gruber
- Neurosurgery and Neuroradiology, University Hospital, Lintz, Austria
| | | | - Mika Niemela
- Neurosurgery, University Hospital, Helsinki, Finland
| | | | | | - Bengt Karlsson
- Radiosurgery, Singapore Gamma Knife Center, Singapore, Singapore
| | - Andras Kemeny
- Radiosurgery, Thornbury Radiosurgery Centre, Sheffield, UK
| | - Roman Liscak
- Radiosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Bodo Lippitz
- Radiosurgery, Bupa Cromwell Hospital, London, UK
| | | | | | - René Chapot
- Neuroradiology, Krupp Hospital, Hessen, Germany
| | - Civan Islak
- Neuroradiology, Cerrahpaşa Medical Faculty, İstanbul University, Istanbul, Turkey
| | - Laurent Spelle
- Neuroradiology, Bicetre University Hospital, Paris, France
| | | | - Elio Agostoni
- Neurology, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Revay
- Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Kozyrev DA, Thiarawat P, Jahromi BR, Intarakhao P, Choque-Velasquez J, Hijazy F, Teo MK, Hernesniemi J. "Dirty coagulation" technique as an alternative to microclips for control of bleeding from deep feeders during brain arteriovenous malformation surgery. Acta Neurochir (Wien) 2017; 159:855-859. [PMID: 28283870 DOI: 10.1007/s00701-017-3138-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 02/27/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Meticulous haemostasis is one of the most important factors during microneurosurgical resection of brain arteriovenous malformation (AVM). Controlling major arterial feeders and draining veins with clips and bipolar coagulation are well-established techniques, while managing with bleeding from deep tiny vessels still proves to be challenging. This technical note describes a technique used by the senior author in AVM surgery for last 20 years in dealing with the issue highlighted. METHOD "Dirty coagulation" is a technique of bipolar coagulation of small feeders carried out together with a thin layer of brain tissue that surrounds these fragile vessels. The senior author uses this technique for achieving permanent haemostasis predominantly in large and/or deep-seated AVMs. To illustrate the efficacy of this technique, we retrospectively reviewed the outcome of Spetzler-Martin (SM) grade III-V AVMs resected by the senior author over the last 5 years (2010-2015). RESULTS Thirty-five cases of AVM surgeries (14 SM grade III, 15 SM grade IV and 6 SM grade V) in this 5-year period were analysed. No postoperative intracranial haemorrhage was encountered as a result of bleeding from the deep feeders. Postoperative angiograms showed complete resection of all AVMs, except in two cases (SM grade V and grade III). CONCLUSIONS "Dirty coagulation" provides an effective way to secure haemostasis from deep tiny feeders. This cost-effective method could be successfully used for achieving permanent haemostasis and thereby decreasing postoperative haemorrhage in AVM surgery.
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Affiliation(s)
- Danil A Kozyrev
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.
- Department of Paediatric Neurology and Neurosurgery, North-Western State Medical University, St. Petersburg, Russia.
| | - Peeraphong Thiarawat
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Patcharin Intarakhao
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Ferzat Hijazy
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mario K Teo
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, UK
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
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O’Donnell JM, Morgan MK, Heller GZ. The Risk of Seizure Following Surgery for Brain Arteriovenous Malformation: A Prospective Cohort Study. Neurosurgery 2017; 81:935-948. [DOI: 10.1093/neuros/nyx101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 02/15/2017] [Indexed: 11/15/2022] Open
Abstract
Abstract
BACKGROUND
The evidence for the risk of seizures following surgery for brain arteriovenous malformations (bAVM) is limited.
OBJECTIVE
To determine the risk of seizures after discharge from surgery for supratentorial bAVM.
METHODS
A prospectively collected cohort database of 559 supratentorial bAVM patients (excluding patients where surgery was not performed with the primary intention of treating the bAVM) was analyzed. Cox proportional hazards regression models (Cox regression) were generated assessing risk factors, a Receiver Operator Characteristic curve was generated to identify a cut-point for size and Kaplan–Meier life table curves created to identify the cumulative freedom from postoperative seizure.
RESULTS
Preoperative histories of more than 2 seizures and increasing maximum diameter (size, cm) of bAVM were found to be significantly (P < .01) associated with the development of postoperative seizures and remained significant in the Cox regression (size as continuous variable: P = .01; hazard ratio: 1.2; 95% confidence interval: 1.0-1.3; more than 2 seizures: P = .02; hazard ratio: 2.1; 95% confidence interval: 1.1-3.8). The cumulative risk of first seizure after discharge from hospital following resection surgery for all patients with bAVM was 5.8% and 18% at 12 mo and 7 yr, respectively. The 7-yr risk of developing postoperative seizures ranged from 11% for patients with bAVM ≤4 cm and with 0 to 2 preoperative seizures, to 59% for patients with bAVM >4 cm and with >2 preoperative.
CONCLUSION
The risk of seizures after discharge from hospital following surgery for bAVM increases with the maximum diameter of the bAVM and a patient history of more than 2 preoperative seizures.
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Affiliation(s)
| | | | - Gillian Z Heller
- Department of Statistics, Macquarie University, Sydney NSW, Australia
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Ryu B, Ishikawa T, Kawamata T. Multimodal Treatment Strategy for Spetzler-Martin Grade III Arteriovenous Malformations of the Brain. Neurol Med Chir (Tokyo) 2017; 57:73-81. [PMID: 27169498 PMCID: PMC5341343 DOI: 10.2176/nmc.ra.2016-0056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The Spetzler–Martin (S–M) grading scale was developed to assess the risk of postoperative neurological complications after the surgical treatment of arteriovenous malformations (AVMs) of the brain. Treatment-associated morbidity and poor outcomes are particularly relevant to Grade III AVMs and improving the safety while attaining acceptable cure rates still poses a challenge. A multimodal treatment strategy combining surgery, embolization, and radiosurgery is recommended for S–M Grade III AVMs because of the surgical risk. Grade III AVMs are the heterogeneous group that has been further divided into subgroups according to the size, the location in eloquent cortex, and the presence of deep venous drainage. The risks associated with different treatment modalities vary depending on the subgroup, and the rating scales have been further refined to predict the risk more accurately and help determine the most appropriate treatment choice. Previous results for the treatment of S–M Grade III AVMs vary widely among studies, and the treatment modalities are also different in each study. Being familiar with previous treatment results is essential for improving treatment outcomes.
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Affiliation(s)
- Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University
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Morgan MK, Hermann Wiedmann MK, Stoodley MA, Heller GZ. Microsurgery for Spetzler-Ponce Class A and B arteriovenous malformations utilizing an outcome score adopted from Gamma Knife radiosurgery: a prospective cohort study. J Neurosurg 2016; 127:1105-1116. [PMID: 28009228 DOI: 10.3171/2016.8.jns161275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to adapt and apply the extended definition of favorable outcome established for Gamma Knife radiosurgery (GKRS) to surgery for brain arteriovenous malformations (bAVMs). The aim was to derive both an error around the point estimate and a model incorporating angioarchitectural features in order to facilitate comparison among different treatments. METHODS A prospective microsurgical cohort was analyzed. This cohort included patients undergoing embolization who did not proceed to microsurgery and patients denied surgery because of perceived risk of treatment. Data on bAVM residual and recurrence during long-term follow-up as well as complications of surgery and preoperative embolization were analyzed. Patients with Spetzler-Ponce Class C bAVMs were excluded because of extreme selection bias. First, patients with a favorable outcome were identified for both Class A and Class B lesions. Patients were considered to have a favorable outcome if they were free of bAVM recurrence or residual at last follow-up, with no complication of surgery or preoperative embolization, and a modified Rankin Scale score of more than 1 at 12 months after treatment. Patients who were denied surgery because of perceived risk, but would otherwise have been candidates for surgery, were included as not having a favorable outcome. Second, the authors analyzed favorable outcome from microsurgery by means of regression analysis, using as predictors characteristics previously identified to be associated with complications. Third, they created a prediction model of favorable outcome for microsurgery dependent upon angioarchitectural variables derived from the regression analysis. RESULTS From a cohort of 675 patients who were either treated or denied surgery because of perceived risk of surgery, 562 had Spetzler-Ponce Class A or B bAVMs and were included in the analysis. Logistic regression for favorable outcome found decreasing maximum diameter (continuous, OR 0.62, 95% CI 0.51-0.76), the absence of eloquent location (OR 0.23, 95% CI 0.12-0.43), and the absence of deep venous drainage (OR 0.19, 95% CI 0.10-0.36) to be significant predictors of favorable outcome. These variables are in agreement with previous analyses of microsurgery leading to complications, and the findings support the use of favorable outcome for microsurgery. The model developed for angioarchitectural features predicts a range of favorable outcome at 8 years following microsurgery for Class A bAVMs to be 88%-99%. The same model for Class B bAVMs predicts a range of favorable outcome of 62%-90%. CONCLUSIONS Favorable outcome, derived from GKRS, can be successfully used for microsurgical cohort series to assist in treatment recommendations. A favorable outcome can be achieved by microsurgery in at least 90% of cases at 8 years following microsurgery for patients with bAVMs smaller than 2.5 cm in maximum diameter and, in the absence of either deep venous drainage or eloquent location, patients with Spetzler-Ponce Class A bAVMs of all diameters. For patients with Class B bAVMs, this rate of favorable outcome can only be approached for lesions with a maximum diameter just above 6 cm or smaller and without deep venous drainage or eloquent location.
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Affiliation(s)
| | | | | | - Gillian Z Heller
- Statistics, Macquarie University, Sydney, New South Wales, Australia
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Wong J, Slomovic A, Ibrahim G, Radovanovic I, Tymianski M. Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)-Eligible Unruptured Brain Arteriovenous Malformations. Stroke 2016; 48:136-144. [PMID: 27856955 DOI: 10.1161/strokeaha.116.014660] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 09/12/2016] [Accepted: 10/07/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The management of unruptured brain arteriovenous malformations (ubAVMs) remains controversial despite ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation), a controlled trial that suggested superiority of conservative management over intervention. However, microsurgery occurred in only 14.9% of ARUBA intervention cases, raising concerns about the study's generalizability. Our purpose was to evaluate whether, in a larger ARUBA-eligible ubAVM population, microsurgery produces acceptable outcomes. METHODS Demographic data, AVM characteristics, and treatment outcomes were evaluated in 155 ARUBA-eligible bAVMs treated with microsurgery between 1994 and 2014. Outcomes were rates of early disabling deficits and permanent disabling deficits with modified Rankin Scale score ≥3 or any permanent neurological deficits with modified Rankin Scale score ≥1. Covariates associated with outcomes were determined by regression analysis. RESULTS Of 977 AVM patients, 155 ARUBA-eligible patients had microsurgical resection (71.6% surgery only and 25.2% with preoperative embolization). Mean follow-up was 36.1 months. Complete obliteration was achieved in 94.2% after initial surgery and 98.1% on final angiography. Early disabling deficits and permanent disabling deficits occurred in 12.3% and 4.5%, respectively, whereas any permanent neurological deficit (modified Rankin Scale score ≥1) occurred in 16.1%. Among ubAVM of Spetzler-Martin grades 1 and 2, complete obliteration occurred in 99.2%, with early disabling deficits and permanent disabling deficits occurring in 9.3% and 3.4%, respectively. Major bleeding was the only significant predictor of early disabling deficits on multivariate analysis (P<0.001). CONCLUSIONS Microsurgery in this cohort produced less disabling deficits than ARUBA with similar morbidity and AVM obliteration as other cohort series. This disparity between our results and ARUBA suggests that future controlled trials should focus on the safety and efficacy of microsurgery with or without adjunctive embolization in carefully selected ubAVM patients.
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Affiliation(s)
- Johnny Wong
- From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.)
| | - Alana Slomovic
- From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.)
| | - George Ibrahim
- From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.)
| | - Ivan Radovanovic
- From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.)
| | - Michael Tymianski
- From the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Ontario, Canada (J.W., A.S., G.I., I.R., M.T.) and Department of Surgery, University of Toronto, Ontario, Canada (J.W., G.I., I.R., M.T.).
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Heros RC. Editorial. Transdural arterial recruitment to brain arteriovenous malformations. J Neurosurg 2016; 127:47-50. [PMID: 27588587 DOI: 10.3171/2016.6.jns161361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roberto C Heros
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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Bervini D, Morgan MK, Stoodley MA, Heller GZ. Transdural arterial recruitment to brain arteriovenous malformation: clinical and management implications in a prospective cohort series. J Neurosurg 2016; 127:51-58. [PMID: 27588588 DOI: 10.3171/2016.5.jns16730] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The occurrence of transdural arterial recruitment (TDAR) in association with brain arteriovenous malformation (bAVM) is uncommon, and the reason for TDAR is not understood. The aim of this cohort study was to examine patient and bAVM characteristics associated with TDAR and the implications of TDAR on management. METHODS A prospective surgical database of bAVMs was examined. Cases previously treated elsewhere or incompletely examined by digital subtraction angiography (DSA) assessment were excluded. Three studies of this cohort were performed, as follows: characteristics associated with TDAR, the relationship between TDAR and neurological deficits unassociated with hemorrhage (NDUH), and the impact of TDAR on outcome from surgery. Regression models were performed. RESULTS Of 769 patients with complete DSA who had no previous treatment, 51 (6.6%) were found to have TDAR. The presence of TDAR was associated with increasing age (p < 0.01; OR 1.05; 95% CI 1.02-1.07); presentation with NDUH (p < 0.01; OR 2.71; 95% CI 1.29-5.71); increasing size of the bAVM (p < 0.01; OR 1.57; 95% CI 1.29-1.91); and combined supply from both anterior and posterior circulations (p = 0.02; OR 2.37; 95% CI 1.17-4.78). Further analysis of TDAR cases comparing those with and without NDUH found an association of larger size (6.6 cm [2.9 SD] compared with 4.7 cm [1.8 SD]; p < 0.01) and combined supply from both anterior and posterior circulations (relative risk 2.5; 95% CI 1.0-6.2; p = 0.04) to be associated with an NDUH presentation. For the 632 patients undergoing surgery there was an increased risk of complications (where this produced a new permanent neurological deficit at 12 months represented by a modified Rankin Scale score of > 1) with the following variables: size; location in eloquent brain; deep venous drainage; increasing age; and no presentation with hemorrhage. The presence of TDAR was not associated with an increased risk of complications from surgery. CONCLUSIONS The authors found that TDAR occurs in older patients with larger bAVMs, and that TDAR is also more likely to be associated with bAVMs presenting with NDUH. The likely explanation for the presence of TDAR is a secondary recruitment arising as a consequence of shear stress, rather than a primary vascular supply present from the earliest development of the bAVM.
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Affiliation(s)
- David Bervini
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland; and.,Departments of 2 Clinical Medicine and
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Morgan MK, Stoodley MA, Fuller JW. Letter to the Editor: Comparison between surgery and Gamma Knife radiosurgery for brain AVMs. J Neurosurg 2016; 126:338-341. [PMID: 27471894 DOI: 10.3171/2016.3.jns16634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Teo MK, Young AMH, St George EJ. Comparative surgical outcome associated with the management of brain arteriovenous malformation in a regional neurosurgical centre. Br J Neurosurg 2016; 30:623-630. [PMID: 27341061 DOI: 10.1080/02688697.2016.1199776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Microsurgical resection of brain arteriovenous malformation (AVMs) is challenging, however, expert surgical series from large volume centres, have reported over 95% occlusion rates with 2 to 8% risk of morbidity & mortality. Data from a regional neurosurgical unit was analysed and compared with published series for the purposes of quality control. We also compared our surgical result with other treatment modalities from the whole AVM cohort managed over the same study period. DESIGN Retrospective analysis of a locally held AVM database. SUBJECTS Of the 141 AVM patients, 54 (35M, 19F, age range 9-68 years) underwent microsurgical removal of AVM by the senior author, from 2006 to 2012. 27 (19%), 18 (13%), 20 (14%), 22 (16%) had endovascular therapy only, radiosurgery only, combination therapy (endovascular and radiosurgery) and conservative management, respectively. METHODS Case notes were reviewed to determine clinical and radiological outcomes. Statistical analysis performed using SPSS with p < 0.05 defined as statistical significance. RESULTS In the surgical series, the Spetzler-Martin (SM) grade distribution was as follows: 17 grade I (32%), 31 grade II (57%), and 6 grade III (11%). 31 patients (57%) presented with intracranial haemorrhage, 12 patients (22%) with seizures. Of the 54 patients, 51 (94%) had angiographically confirmed obliteration of their AVM. Median follow-up for the entire cohort was 7 years. 83% of surgical patients have mRS 0-1, compared to 78%, 67%, 45%, 18% of patients managed by endovascular therapy, radiosurgery, combination therapy, conservative surveillance, respectively (p < 0.0001). However, the groups were not comparable in terms of SM grade or clinical presentation and the numbers in each group were relatively small. Seizure presentations were encountered in 23% (32/141) of the overall patients, and all the surviving patients were on anticonvulsants, except in the surgical arm, 7/12 (58%) patients were off their antiepileptic medications at last follow-up. CONCLUSIONS The results demonstrate a 94% surgical obliteration rate and 11% long-term neurological deficits for brain AVM patients managed surgically and were comparable to expert series. Achieving acceptable results is possible in lower volume settings, however, patient selection is important and the role of an experienced neurovascular team cannot be overstated.
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Affiliation(s)
- Mario K Teo
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
| | - Adam M H Young
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
| | - Edward J St George
- a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK
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Modified Rankin Scale and Short-Term Outcome in Cranial Neurosurgery: A Prospective and Unselected Cohort Study. World Neurosurg 2016; 91:567-573.e7. [PMID: 27060513 DOI: 10.1016/j.wneu.2016.03.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The modified Rankin Scale (mRS) was developed to monitor functional recovery after stroke, but nowadays it is a treatment outcome measure in elective neurosurgery. Our objective was to study how mRS changes associate with short-term postoperative outcome. METHODS Preoperative, in-hospital, and 30-day mRS scores came from a prospective, consecutive and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 in Helsinki, Finland. Recorded data included subjective and objective postoperative in-hospital complications as well as changes in mRS score after surgery. RESULTS Minor or major complications were detectable in 46% of the patients. In-hospital and 30-day postoperative increases in mRS score were inconsistent; among patients with no complications, 17% had a greater mRS score at discharge and 24% at 30 days, whereas 28% of the patients with major complications showed no increase in mRS score at discharge. Of individual complications, only new or worsened hemiparesis, silent stroke, and pneumonia were associated with postoperative increase (>2) in mRS score after multivariable analysis. For mRS-score difference > 1 at discharge in detecting major complications (including mortality), sensitivity was 45% and specificity 94%. CONCLUSIONS The mRS changes after elective cranial neurosurgery are inconsistent. The mRS seems to represent functional changes, which do not necessarily associate with detected in-hospital complications.
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Morgan MK, Wiedmann M, Assaad NN, Heller GZ. Complication-Effectiveness Analysis for Brain Arteriovenous Malformation Surgery. Neurosurgery 2015; 79:47-57. [DOI: 10.1227/neu.0000000000001144] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Intervention for brain arteriovenous malformations (bAVMs) should aim at treatment that is safe and effective.
OBJECTIVE:
To analyze a prospective database to derive the probability of neurological deficit and adjust this risk for effectively treated bAVMs (complication-effectiveness analysis [CEA]).
METHODS:
First, we calculated the percentage of surgical complications leading to a modified Rankin Scale >1 at 12 months after surgery for each Spetzler-Ponce class (SPC). Second, we performed a sensitivity analysis of these results by including bAVMs not undergoing surgery, to correct for bias. Third, we established the long-term cumulative incidence of freedom from recurrence from Kaplan-Meier analysis. Finally, we combined the results to calculate the risk of surgery per effective treatment in a complication-effectiveness analysis.
RESULTS:
Seven hundred seventy-nine patients underwent 641 microsurgical resections. Complications of surgery leading to a modified Rankin Scale >1 at 12 months occurred in 1.4% (95% confidence interval [CI]: 0.5-3.3), 20% (95% CI: 15-26), and 41% (95% CI: 30-52) of SPC A, SPC B, and SPC C, respectively. The cumulative 9-year freedom from recurrence was 97% for SPC A and 92% for other bAVMs. The 9-year CEA risk was 1.4% (credible range: 0.5%-3.4%) for SPC A, 22% to 24% (credible range: 16%-31%) for SPC B, and 45% to 63% (credible range: 33%-73%) for SPC C bAVM.
CONCLUSION:
CEA presents the treatment outcome in the context of efficacy and provides a basis for comparing outcomes from techniques with different times to elimination of the bAVM.
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Affiliation(s)
- Michael Kerin Morgan
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Markus Wiedmann
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Nazih N Assaad
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
| | - Gillian Z. Heller
- Department of Statistics, Macquarie University, Sydney, New South Wales, Australia
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Microsurgical resection of Spetzler-Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management--results of a single group series. Acta Neurochir (Wien) 2015; 157:1279-87. [PMID: 26144566 DOI: 10.1007/s00701-015-2474-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The therapeutic benefits of microsurgery for unruptured brain AVM remain unclear. METHODS A series of 97 microsurgically resected unruptured brain AVM was analyzed in terms of postoperative morbidity and lifetime loss of quality-adjusted life-years (QALY). For comparison, the natural risk of becoming disabled was modeled on the basis of published data. RESULTS Discharge morbidity was recorded in 11 of the 69 of Spetzler-Martin (SM) grade 1 and 2 AVMs (16 %), eight of 22 (36 %) grade 3, and four of six grade 4 (67 %), permanent morbidity >mRS 1 in 3 (4.3 %) grade 1 and 2, four (18 %) grade 3, and three (50 %) grade 4. Treatment inflicted loss of QALY amounted to 0.5 years for SM grade 1-2, 2.5 years grade 3, 7.3 years for grade 4. For the SM grades 1 and 2, the treatment-related loss of 0.5 QALY was met by the natural course after 2.7-4.3 years. For the Spetzler-Martin grades 3 and 4, the treatment-induced loss QALY was not met by the natural risk within a foreseeable time. Permanent morbidity and treatment inflicted loss of QALY of patients younger than 39 years was lower than that of older patients (7 vs. 15 % and 1.0 vs. 2.1 QALY). CONCLUSIONS Microsurgically managed SM grades 1 and 2 fared better than the modeled natural course but grades 3 and 4 AVM did not benefit from surgery. Younger patients appear to fare more favorably than older patients.
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Meling TR. Microsurgical resection of unruputured Spetzler-Ponce grade A arteriovenous malformations is worthwhile and still the "gold standard" therapy. Acta Neurochir (Wien) 2015; 157:1289-90. [PMID: 26093621 DOI: 10.1007/s00701-015-2476-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
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Reinard KA, Pabaney AH, Basheer A, Phillips SB, Kole MK, Malik GM. Surgical Management of Giant Intracranial Arteriovenous Malformations: A Single Center Experience over 32 years. World Neurosurg 2015; 84:1765-78. [PMID: 26232210 DOI: 10.1016/j.wneu.2015.07.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 07/20/2015] [Accepted: 07/20/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment of giant intracranial arteriovenous malformations (gAVMs) is a formidable challenge for neurosurgeons and carries significant morbidity and mortality rates for patients compared with smaller AVMs. In this study, we reviewed the treatments, angiographic results, and clinical outcomes in 64 patients with gAVMs who were treated at Henry Ford Hospital between 1980 and 2012. METHODS The arteriovenous malformation (AVM) database at our institution was queried for patients with gAVMs (≥ 6 cm) and data regarding patient demographics, presentation, AVM angioarchitecture, and treatments were collected. Functional outcomes as well as complications were analyzed. RESULTS Of the 64 patients, 33 (51.6%) were female and 31 (48.4%) were male, with an average age of 45.7 years (SD ± 15.5). The most common symptoms on presentation were headaches (50%), seizures (50%), and hemorrhage (41%). The mean AVM size was 6.65 cm (range, 6-9 cm). Only 6 AVMs (9.4%) were located in the posterior fossa. The most common Spetzler-Martin grade was V, seen in 64% of patients. Of the 64 patients, 42 (66%) underwent surgical excision, 10 (15.5%) declined any treatment, 8 (12.5%) were deemed inoperable and followed conservatively, 2 (3%) had stand-alone embolization, 1 (1.5%) had embolization before stereotactic radiosurgery, and 1 (1.5%) received stereotactic radiosurgery only. Complete obliteration was achieved in 90% of the surgical patients. Mortality rate was 19% in the surgical cohort compared with 22% in the observation cohort (P = 0.770). CONCLUSIONS Treatment of gAVMs carries significant morbidity and mortality; however, good outcomes are attainable with a multimodal treatment approach in carefully selected patients.
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Affiliation(s)
- Kevin A Reinard
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Aqueel H Pabaney
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
| | - Azam Basheer
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Scott B Phillips
- Division of Neurological Surgery, Brooks Army Medical Center, San Antonio, Texas, USA
| | - Max K Kole
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ghaus M Malik
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
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Abstract
OPINION STATEMENT Arteriovenous malformations (AVMs) pose a risk of morbidity and mortality throughout an affected patient's lifetime. Over the course of a patient's life, the risk of hemorrhage is approximately 1-4 % per year, and after an initial hemorrhage occurs, this risk may be higher. Other causes of morbidity include seizures, headaches, or progressive neurologic deficits. Once an AVM has been discovered, the utility of attempted obliteration or surgical resection compared to the risk of intervention should be entertained. The characteristics of the malformation as well as the patient's overall health status contribute to the decision to intervene on these lesions. For small lesions located in superficial areas without high-risk surgical characteristics (low-grade Spetzler-Martin grades), it is reasonable to consider surgical resection. In lesions that pose high-risk of complications from surgical removal, intra-arterial embolization, radiosurgery, or a combination of the two may be reasonable treatment options. Some AVMs at traditional high surgical risk may be amenable to partial embolization, allowing initially high-risk lesions to become better candidates for surgical resection. In some patients, particularly those who are older or who have multiple medical comorbidities, the risk of intervention as compared to the annual hemorrhage risk may warrant conservative management as opposed to intervention. The overall treatment strategy must be based on patient and AVM characteristics and careful risk-benefit ratio analysis.
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Morgan MK, Assaad N, Korja M. Surgery for Unruptured Spetzler-Martin Grade 3 Brain Arteriovenous Malformations. Neurosurgery 2015; 77:362-9; discussion 369-70. [DOI: 10.1227/neu.0000000000000774] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
There is uncertainty regarding the management of unruptured Spetzler-Martin grade 3 brain arteriovenous malformations (SMG3 ubAVM).
OBJECTIVE:
To analyze our series of patients treated by surgery.
METHODS:
A single-surgeon database of consecutively enrolled bAVMs (between 1989 and 2014) was analyzed. Adverse outcomes due to surgery were assigned within the first 6 weeks following surgery and outcome was prospectively recorded and assigned at the last follow-up visit by using modified Rankin Scale (mRS) score.
RESULTS:
Of the 137 reviewed patients, 112 (82%) were treated by surgery, 15 (11%) were treated elsewhere or by radiosurgery, and 10 (7%) were recommended for conservative management. Surgery for SMG3 ubAVM was associated with adverse outcomes with a new permanent neurological deficit of mRS >1 in 23 of 112 (21%) patients. Permanent neurological deficit leading to a mRS >2 from surgery was 3.6% (95% confidence interval, 1.1%-9.1%). Late recurrence of a bAVM occurred in 3 of 103 (2.9%) patients who had complete obliteration of bAVM confirmed immediately after surgery and who were subsequently later followed with radiological studies during the mean follow-up period of 3.0 years (range, 6 days to 18.8 years).
CONCLUSION:
When discussing surgical options for SMG3 ubAVM, a thorough understanding of the significance and incidence of adverse events and outcomes is required to fully inform patients. For our series, the additional subclassification of SMG ubAVM (based on variables contributing to the SMG or age) would not have been of use.
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Affiliation(s)
- Michael Kerin Morgan
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW, Australia
| | - Nazih Assaad
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW, Australia
| | - Miikka Korja
- Australian School of Advanced Medicine, Macquarie University, Sydney, NSW, Australia
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
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