Intraoperative Neuromonitoring for Cerebral Arteriovenous Malformation Embolization: A Propensity-Score Matched Retrospective Database Study

Abstract

Introduction The treatment of cerebral arteriovenous malformations (AVMs) may result in neurologic morbidity, particularly when an AVM is located in or adjacent to eloquent brain regions. Intraoperative neurophysiologic monitoring (IONM) may be utilized to reduce the risk of iatrogenic injury during endovascular AVM embolization; however, IONM for endovascular AVM embolization is not ubiquitously the standard of care. Methods Admissions for AVM embolization were assessed from the IBM MarketScan® Commercial and Medicare Supplemental databases (IBM Watson Health, Somers, NY). Inclusion criterion for patients was continuous enrollment six months before and after the index encounter. The use of IONM and presence of intracranial hemorrhage (ICH) were noted. Propensity-score matched cohorts with and without IONM were generated to minimize bias between treatment groups (adjusting for age, sex, and comorbidities). Results From 2007 to 2016, there were 16,279 patients diagnosed with cerebral AVM in the MarketScan database. Embolized patients were stratified into IONM and non-IONM cohorts; there were 357 patients in the IONM cohort and 1775 patients in the non-IONM cohort. Provider types were significantly different between cohorts (p<0.005). Unruptured AVMs were significantly more likely to be embolized with adjunctive IONM (17.7%) compared to ruptured AVMs (7.9%) (p<0.005). After balancing for baseline comorbidities, there were 266 patients in the IONM cohort, and 1347 patients in the non-IONM cohort. Among unruptured AVM patients, IONM was linked to a significantly shorter length of stay (2.72 versus 4.92 days; p<0.005), significantly lower rates of complications within 30 days of discharge (0.00% versus 1.88%; p=0.038), and significantly lower total payment ($40,179 versus $50,844; p<0.0001). Conclusion Endovascular embolization for unruptured AVMs performed with adjunctive IONM was associated with shorter length of stay, lower complication rates, and hospitalization costs.

Intraoperative Monitoring Cerebral Blood Flow During the Treatment of Brain Arteriovenous Malformations in Hybrid Operating Room by Laser Speckle Contrast Imaging

“…Routine intraoperative DSA after microsurgical resection can identify the AVM remnant directly for one-stop resection (12,27). Preoperative partial embolization of the malformation can assist in surgical positioning and decrease blood flow of the malformation, which contributes to minimizing the risk of intraoperative bleeding (28)(29)(30)(31). However, after bAVM resection, excessive perfusion of adjacent cortical tissue and pathological increase of local intravascular pressure (32)(33)(34), may generate cerebral hemorrhage or edema, which worsens the postoperative course.…”

Endovascular Embolization of Ruptured Intracranial Arteriovenous Malformation: A Retrospective Analytic Study

“…A danger of iatrogenic harm to deep or expressive brain areas exists with treatment of these lesions. According to meta-analyses of extensive AVM case series, up to 7.4% of patients having microsurgery for AVM excision may experience serious side effects (9) . Endovascular embolization could serve as a curative option for AVM treatment with accepted morbidity and mortality (10) .…”

Long-Term Outcomes after Endovascular Oblitraion of Pediatric Arteriovenous Malformation : A Multi-Center Analysis

“…In addition, the preponderance of large parenchymal bleeding is common in those young populations. 2,[13][14][15] Children are not young adults, and the management protocols of the adult populations may not be suitable for them. However, these approaches may be applied with suitable modifications.…”