A Discriminative Prediction Model of Neurological Outcome for Patients Undergoing Surgery of Brain Arteriovenous Malformations

Abstract

Background and Purpose-To develop and validate a discriminative model for predicting neurological morbidity after brain arteriovenous malformation (bAVM) surgery. Methods-Of 233 consecutive, prospectively enrolled patients undergoing bAVM surgery, the first 175 were used to derive, and the last 58 to validate, the prediction model. Demographic and angiographic factors were related to modified Rankin Scale scores assigned before, within 72 hours, at 7 days and at Ն1 year after surgery to seek predictors of postoperative neurological deficits (modified Rankin Scale score Ն3). These factors included nidus size, eloquence, venous drainage, diffuseness, white matter configuration, arterial perforator supply and associated aneurysms. Results-Brain eloquence, diffuse nidus and deep venous drainage were significant predictors of early disabling neurological deficits (odds ratios of 4.33, 3.49 and 2.38, respectively). The rounded odds ratios form a weighted 9-point prediction model (maximum scores for eloquenceϩdiffusenessϩdeep drainageϭ4ϩ3ϩ2). The score discriminated the probability of experiencing both early (first week) and permanently (at Ն1 year) disabling neurological deficits as follows: 0 to 2: 1.8%, 3 to 5: 17.4%, 6 to 7: 31.6%, Ͼ7: 52.9% for early and 0 to 2: 1.8%, 3 to 5: 4.4%, 6 to 7: 18.4%, Ͼ7: 32.4% for permanently disabling outcomes. The discrimination of the model was 0.80 with 2.8% optimism. Validation in the second patient cohort revealed good performance at risk stratification. Conclusions-Relative weights assigned to brain eloquence, diffuse nidus morphology and deep venous drainage of a bAVM provide a simple and discriminative prediction model for neurological outcome after bAVM surgery. (Stroke.

Microsurgery for ARUBA Trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation)–Eligible Unruptured Brain Arteriovenous Malformations

“…The risks of treatment are not homogeneous where treatment strategies depend on characteristics of the lesion, availability of individual treatment modalities, and institutional expertise. 10,12,17,[31][32][33][34] Several retrospective series have recently been published on ubAVMs. The SIVMS (Scottish Intracranial Vascular Malformation Study) reported on ubAVMs comparing conservative management with intervention, which also found superiority in the conservative group for death or handicap at 4 years and focal neurological deficit or death at 12 years.…”

Racial/Ethnic Differences in Longitudinal Risk of Intracranial Hemorrhage in Brain Arteriovenous Malformation Patients

“…Sensitivity analysis (model C) restricted to the subset of cases included in model B found that the HR for Hispanics, 26 This may be explained by a fundamentally weaker association of anatomic factors with ICH or more likely because of variability in interpretation of imaging studies. [27][28][29] For example, Al-Shahi et al [27][28][29] studied descriptors determined by catheter angiography and found interobserver agreement ranging from 14% to 62%, generally worse for characteristics associated with more complex angioarchitecture. Of note was low interobserver agreement involving the measurement of Spetzler-Martin grade (47%) and the presence of aneurysms (40%), 2 variables that arguably bear some importance in patient management decisions.…”

“…More recent studies incorporating MRI findings found only modest improvement in interobserver agreement with kappas ranging from 38% to 90%. 28,29 Furthermore, we did not adjust for BAVM location or associated aneurysms in our multivariate model because these data were not available for KPMCP patients at the time of analysis, which may also explain some differences from previous natural history studies of BAVM.…”

Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study

“…26 Some series reported the lack of impact of size or eloquent location of AVMs on surgical outcome. 14,24 This may be explained by cohort surgical series that do not take into consideration patients at high risk because they have been excluded from surgical treatment. Davidson and Morgan attempted to account for the patients who had been excluded from surgical treatment and concluded that all the variables of the Spetzler-Martin grading system were of importance and that the Spetzler-Martin grading system was a reliable way of stratifying risks from surgery.…”