Significance of factors contributing to surgical complications and to late outcome after elective surgery of cerebral arteriovenous malformations

Schaller, Carlo; Schramm, Johannes; Haun, Dorothee

doi:10.1136/jnnp.65.4.547

Cited by 78 publications

(32 citation statements)

References 44 publications

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“…As in Spetzler's and Martin's own analysis, the grading system's individual elements show different effect magnitudes: increasing AVM size appeared to be a stronger determinant than deep venous drainage, and eloquence of locationalthough significant at immediate postoperative examination-had no significant effect at long-term follow-up or in multivariate logistic regression analyses. Other studies 14 have shown similar results. Further weakening the predictive value of the grading system, the 3 elements are not independent: with increasing AVM size, an eloquent brain location and a deep venous drainage component must become more frequent.…”

Section: Discussionsupporting

confidence: 79%

Determinants of Neurological Outcome After Surgery for Brain Arteriovenous Malformation

Hartmann

Stapf

Hofmeister

et al. 2000

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133

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Background and Purpose-We sought to define determinants of neurological deficit after surgery for brain arteriovenous malformation (AVM). Methods-One hundred twenty-four prospective patients (48% women, mean age 33 years) underwent microsurgical brain AVM resection. Patients were examined by 3 study neurologists immediately before surgery, postoperatively in-hospital, by in-person long-term follow-up, and with a structured telephone follow-up. . At long-term follow-up (mean follow-up time 12 months), 47 patients (38%) revealed surgery-related neurological deficits (6% disabling; 32% nondisabling). The rate of neurological complications increased by Spetzler-Martin grade. Female gender, AVM size, and deep venous drainage were significantly associated with neurological deficits at in-hospital and long-term evaluation. For patient age and AVM location, no significant association was found. Conclusions-The findings suggest that female gender, AVM size, and AVM drainage into the deep venous system may be determinants of neurological deficit after microsurgical AVM resection.

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Section: Discussionsupporting

confidence: 79%

Determinants of Neurological Outcome After Surgery for Brain Arteriovenous Malformation

Hartmann

Stapf

Hofmeister

et al. 2000

Stroke

133

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“…Although invasive treatments of highly eloquent lesions are associated with poor clinical outcome, 27 in our series 90% of the patients had mRS scores of 0-2 at 6 months. Moreover, our rate of single-session total nidus obliteration (95%) is the highest reported so far, even compared with series with cortical localizations or lower SpetzlerMartin grades.…”

Section: Discussionmentioning

confidence: 94%

Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

Iosif¹,

Mendes²,

Saleme³

et al. 2015

JNS

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OBJECT Ruptured cerebral arteriovenous malformations (AVMs) with deep localization and high Spetzler-Martin grades are associated with considerable challenges regarding nidus eradication treatment. The authors report their experience with curative endovascular transvenous embolization in a series of patients harboring “untreatable” lesions. METHODS Between January 2008 and June 2013, a transvenous endovascular embolization protocol was implemented at the authors' institution for consecutive patients with ruptured brain AVMs that were considered incurable by classic endovascular and surgical techniques. Therapeutic decision making was based on Spetzler-Martin grades, AVM location, type of venous drainage, and angioarchitectural evaluation. Complete exclusion of the nidus was the objective of treatment. RESULTS Twenty patients (10 male and 10 female, mean age 36.7 ± 17.7 years) were included. Initial Spetzler-Martin grades were III–V for 90.0% of the patients. The lesions were deeply seated in 80% and in eloquent locations in 90% of cases. The preprocedural modified Rankin Scale score was 0–2 for 12 of the 20 patients (60.0%), 3 for 2 patients (10.0%), and 4 for 6 patients (30.0%). The postprocedural clinical status was unchanged for all patients. The procedure was technically feasible in all cases. Procedure-related mortality was 0%. Ninety percent of the patients were independent in their everyday lives (modified Rankin Scale Scores 0–2) at the 6-month follow-up. In all cases but one (95%) the embolization was curative, confirmed by selective DSA at 6 months and 18 months postintervention. CONCLUSIONS Single-session endovascular transvenous embolization seems to be a safe and effective curative treatment for patients harboring complex brain AVMs with high Spetzler-Martin grade.

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“…5,13,23,25,26 The importance of this grading system is to assist in selection of cases with a low risk of permanent adverse outcomes from surgery. It has been recommended by Spetzler and Ponce that the grading system can best be reduced to 3 tiers: Spetzler-Martin Grades I and II (Spetzler-Ponce Class A), Spetzler-Martin Grade III (Spetz lerPonce Class B), and Spetzler-Martin Grades IV and V (Spetzler-Ponce Class C).…”

mentioning

confidence: 99%

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

Bervini¹,

Morgan²,

Ritson

et al. 2014

JNS

102

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Object The aim of this study was to identify patients who are likely to benefit from surgery for unruptured brain arteriovenous malformations (ubAVMs). Methods The authors' database was interrogated for the risk and outcome of hemorrhage after referral and the outcome from surgery. Furthermore, the outcome from surgery incorporated those cases excluded from surgery because of perceived greater risk (sensitivity analysis). Finally, a comparison was made for the authors' patients between the natural history and surgery. Data were collected for 427 consecutively enrolled patients with ubAVMs in a database that included patients who were conservatively managed. Kaplan-Meier analysis was performed on patients observed for more than 1 day to determine the risk of hemorrhage. Variables that may influence the risk of first hemorrhage were assessed using Cox proportional hazard regression models and Kaplan-Meier life table analyses from referral until the first occurrence of the following: hemorrhage, treatment, or last review. The outcome from surgery (leading to a new permanent neurological deficit with last review modified Rankin Scale [mRS] score > 1) was determined. Further sensitivity analysis was made to predict risk from surgery for the total ubAVM cohort by incorporating outcomes of surgical cases as well as cases excluded from surgery because of perceived risk, and assuming an adverse outcome for these excluded cases. Results A total of 377 patients with a ubAVM were included in the analysis of the risk of hemorrhage. The 5-year risk of hemorrhage for ubAVM was 11.5%. Hemorrhage resulted in an mRS score > 1 in 14 cases (88% [95% CI 63%–98%]). Patients with Spetzler-Ponce Class A ubAVMs treated by surgery (n = 190) had a risk from surgery of 1.6% (95% CI 0.3%–4.8%) for a permanent neurological deficit leading to an mRS score > 1 and 0.5% (95% CI < 0.1%–3.2%) for a permanent neurological deficit leading to an mRS score > 2. Patients with Spetzler-Ponce Class B ubAVMs treated by surgery (n = 107) had a risk from surgery of 14.0% (95% CI 8.6%–22.0%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Spetzler-Ponce Class B ubAVMs, including those in patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 15.6% (95% CI 9.9%–23.7%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Patients with Spetzler-Ponce Class C ubAVMs treated by surgery (n = 44) had a risk from surgery of 38.6% (95% CI 25.7%–53.4%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Class C ubAVMs, including those harbored by patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 60.9% (95% CI 49.2%–71.5%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Conclusions Surgical outcomes for Spetzler-Ponce Class A ubAVMs are better than those for conservative management.

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Significance of factors contributing to surgical complications and to late outcome after elective surgery of cerebral arteriovenous malformations

Cited by 78 publications

References 44 publications

Determinants of Neurological Outcome After Surgery for Brain Arteriovenous Malformation

Determinants of Neurological Outcome After Surgery for Brain Arteriovenous Malformation

Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

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

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