Management of arteriovenous malformations in the elderly: a single-center case series and analysis of outcomes

Abstract

A rteriovenous malformations (AVMs) are congenital vascular lesions with an incidence of 1-1.14 cases per 100,000 persons and an annual rate of hemorrhage around 2%-4% in untreated patients.1,11 While female sex, subcortical location, prior rupture history, deep venous drainage, and association with intracranial aneurysms have previously been identified as risk factors that could increase the risk of hemorrhage, 2 a recent meta-analysis showed that every 10 additional years in patient age correlates with an approximately 30% increase in the risk of AVM rupture. 16 Additionally, while longitudinal population-based studies have demonstrated that most brain AVMs (bAVMs) become symptomatic in the fourth and fifth decade of life and may, consequently, be infrequently encountered in the elderly population, 22 conflicting reports suggest that the course of bAVMs in the elderly is not benign and that a preponderance of bAVMs in this age group present with hemorrhage. 8,12 While the natural history of bAVMs is widely described, only a limited number of reports have exclusively focused on the natural history and management of bAVMs in the elderly population. 12,13,17 Because of this, and as a result of the absence of consensus guidelines for the management of bAVMs in the elderly population, treatment of these complex vascular lesions in the elderly will continue to challenge cerebrovascular surgeons, especially in light of the ubiquity of diagnostic brain imaging tools 10 and a concomitant rise in global life expectancy. 19,25With remarkable advances in endovascular technology, radiation therapy, as well as microsurgical techniques, multimodality management of bAVMs has proven effective and safe across various age groups. methods The bAVM database at the authors' institution was queried for records of elderly patients with bAVMs, and data regarding patient demographics, presenting symptoms, bAVM angioarchitecture, treatment modalities, angiographic results, clinical outcomes, and treatment complications were tabulated and analyzed. results There were 9 male (32%) and 19 female (68%) patients, with an average age (± SD) of 73.0 ± 6.95 years.The most common symptoms on presentation were hemorrhage (36%) and headaches (18%). The bAVMs were equally distributed between the supra- and infratentorial compartments. The most common Spetzler-Martin grade was II, observed in 57% of the patients. Eleven patients (39.3%) underwent resection, 4 patients (14.3%) received standalone radiation therapy, and 13 patients (46%) did not receive treatment or were managed expectantly. Four patients (14.3%) were lost to follow-up. Complete bAVM obliteration was achieved in 87% of the treated patients. None of the patients who received any form of treatment died; the overall mortality rate was 3.6%. coNclusioNs Surgical management of bAVMs in the elderly can result in complete obliteration and acceptable clinical outcomes.

Microsurgical resection of brain arteriovenous malformations in the elderly: outcomes analysis and risk stratification

“…9 A recently published single-center, retrospective review of 28 AVM patients older than 65 years also demonstrated hemorrhage as the most common symptom of patients on presentation. 16 This was confirmed in our analysis, with rupture observed in 49% of patients older than 60 years.…”

“…The limited number of studies investigating surgical outcomes in elderly patients 4,10,16,21 is confounded by small sample sizes and/or heterogeneous application of treatment modalities (endovascular embolization, preoperative embolization, microsurgical resection, and radiosurgery). The aging population and refinement of neuroimaging modalities have led to higher AVM detection rates in patients older than 60 years.…”

Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey

“…Many previous studies proposed that elderly bAVMs were interventional contraindication, because only a life expectancy over 20 years could be a prerequisite for treatment [20], and the risk of treatment can outweigh the risk of bleeding. However, Pabaney et al proposed surgical management of elderly bAVMs can result in complete obliteration and acceptable clinical outcomes, with an overall mortality rate of 3.6% and an obliteration rate of 87% [23]. In this study, most participants agreed that elderly patients should receive intervention management, but more minimally invasive and lower risk strategies were recommended, such as partial occlusion of hemorrhagic risk factors.…”

Role of age-related alterations of the cerebral venous circulation in the pathogenesis of vascular cognitive impairment

“…Another line of evidence supporting an important role of venous aging in the pathogenesis of intracerebral hemorrhages comes from studies on arteriovenous malformations (AVMs) (134). AVMs are congenital vascular lesions (incidence:~1 per 100,000 persons).…”