Seizure Predictors and Control After Microsurgical Resection of Supratentorial Arteriovenous Malformations in 440 Patients

Abstract

Background Seizures are a common symptom of supratentorial arteriovenous malformations (AVMs), and uncontrolled epilepsy can considerably reduce patient quality-of-life. Potential risk factors for epilepsy in patients with AVMs are poorly understood, and the importance of achieving seizure-freedom in their surgical treatment remains under-appreciated. Objective To characterize risks factors for pre-operative seizures and factors associated with post-operative seizure-freedom in patients with surgically resected supratentorial AVMs. Methods We analyzed prospectively-collected patient data for 440 patients who underwent microsurgical resection of supratentorial AVMs at our institution. Results Among 440 patients with supratentorial AVMs, 130 (30%) experienced pre-operative seizures, and 23 (18%) individuals with seizures progressed to medically refractory epilepsy. Seizures were associated with a history of AVM hemorrhage (RR 6.65, 95% CI 3.81-11.6), male gender (RR 2.07, 95% CI 1.26-3.39), and frontotemporal lesion location (RR 1.75, 95% CI 1.05-2.93). After resection, 96% of patients had a modified Engel class I outcome, characterized by seizure-freedom (80%) or only one post-operative seizure (16%) (mean follow-up 20.7 ± 2.3 months). Comparable rates of post-operative seizures were seen in patients with (7%) or without (3%) pre-operative seizures. AVMs with deep artery perforators were significantly associated with post-operative seizures (HR 4.35, 95% CI 1.61-11.7). Conclusion In the microsurgical treatment of supratentorial AVMs, hemorrhage, male gender, and frontotemporal location are associated with higher rates of pre-operative seizures, while deep artery perforators are associated with post-operative seizures. Achieving seizure-freedom is an important goal that can be achieved in the surgical treatment of AVMs, as epilepsy can significantly diminish patient quality-of-life.

Seizure control after subtotal lesional resection

“…A recent review of seizures associated with supratentorial cavernous malformations 15 revealed gross-total lesional resection was strongly predictive of postoperative seizure freedom, although extended resection of the surrounding hemosiderin ring was not. A recent single-institution report on seizures after surgical treatment of supratentorial arteriovenous malformations 17 showed excellent seizure results overall with 96% Engel Class I outcomes, although complete lesional obliteration was not associated with better seizure outcomes in this series. This finding was unique among all studies reviewed, except the single high-grade glioma study.…”

“…Seizure outcomes have also been specifically examined for temporal lobe 14 and insular cortex 10,36 tumors. Seizure outcomes for temporal lobe and insular cortex tumors are comparable to those achieved after surgery for nonneoplastic entities including vascular pathologies, such as cavernous malformation 15 and arteriovenous malformation, 17,19 and focal cortical dysplasia. 30 …”

Seizure outcomes following radiosurgery for cerebral arteriovenous malformations

“…49,52,66 The reported risk of new-onset seizures after microsurgical resection varies widely, ranging from 3% to 32%. 1,19,29,33,52,66 In contrast, SRS appears to confer a lower seizure risk for patients without pretreatment seizures, with rates ranging from 0% to 7%. 5,33,69 Current treatment options offer relatively effective seizure control with modality-specific risks and complications.…”

Complicações pós-operatórias em neurocirurgia eletiva e não eletiva

“…Inherent complexities of this population, extended hospital stays, urgent and emergency procedures and secondary complications end-up increasing the basal risk. (1) The most commonly observed neurological complications in the postoperative period of elective skull surgeries include decreased level of consciousness, (1) cerebral vasospasms, (2) refractory seizures, (1,3) reoperation, (4)(5)(6) hemiparesis and intraparenchymal hematoma. (7,8) In non-elective surgeries, intracranial hypertension, (9) motor deficits, (10) recurrent subdural hematoma, (10,11) intraparenchymal hemorrhage, (12) vasospasms, (13) and seizures (10,14) are also reported.…”