Multimodality Management of Spetzler-Martin Grade 3 Brain Arteriovenous Malformations with Subgroup Analysis

2017 ◽  
Vol 102 ◽  
pp. 263-274 ◽  
Author(s):  
Isaac Josh Abecassis ◽  
John D. Nerva ◽  
Abdullah Feroze ◽  
Jason Barber ◽  
Basavaraj V. Ghodke ◽  
...  
Keyword(s):  
Subgroup Analysis ◽  
Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Martin Grade ◽  
Grade 3

Surgery for Unruptured Spetzler-Martin Grade 3 Brain Arteriovenous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 77 (3) ◽  
pp. 362-370 ◽  
Author(s):  
Michael Kerin Morgan ◽  
Nazih Assaad ◽  
Miikka Korja
Keyword(s):  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Late Recurrence ◽  
Adverse Outcomes ◽  
Brain Arteriovenous Malformations ◽  
Complete Obliteration ◽  
Martin Grade ◽  
Grade 3 ◽  
Permanent Neurological Deficit

Abstract BACKGROUND: There is uncertainty regarding the management of unruptured Spetzler-Martin grade 3 brain arteriovenous malformations (SMG3 ubAVM). OBJECTIVE: To analyze our series of patients treated by surgery. METHODS: A single-surgeon database of consecutively enrolled bAVMs (between 1989 and 2014) was analyzed. Adverse outcomes due to surgery were assigned within the first 6 weeks following surgery and outcome was prospectively recorded and assigned at the last follow-up visit by using modified Rankin Scale (mRS) score. RESULTS: Of the 137 reviewed patients, 112 (82%) were treated by surgery, 15 (11%) were treated elsewhere or by radiosurgery, and 10 (7%) were recommended for conservative management. Surgery for SMG3 ubAVM was associated with adverse outcomes with a new permanent neurological deficit of mRS >1 in 23 of 112 (21%) patients. Permanent neurological deficit leading to a mRS >2 from surgery was 3.6% (95% confidence interval, 1.1%-9.1%). Late recurrence of a bAVM occurred in 3 of 103 (2.9%) patients who had complete obliteration of bAVM confirmed immediately after surgery and who were subsequently later followed with radiological studies during the mean follow-up period of 3.0 years (range, 6 days to 18.8 years). CONCLUSION: When discussing surgical options for SMG3 ubAVM, a thorough understanding of the significance and incidence of adverse events and outcomes is required to fully inform patients. For our series, the additional subclassification of SMG ubAVM (based on variables contributing to the SMG or age) would not have been of use.

scholarly journals How Safe Is Arteriovenous Malformation Surgery? A Prospective, Observational Study of Surgery As First-Line Treatment for Brain Arteriovenous Malformations

Neurosurgery ◽  
2010 ◽  
Vol 66 (3) ◽  
pp. 498-505 ◽  
Author(s):  
Andrew S. Davidson ◽  
Michael K. Morgan
Keyword(s):  
Arteriovenous Malformations ◽  
Prospective Observational Study ◽  
First Line ◽  
Surgical Risk ◽  
Brain Arteriovenous Malformations ◽  
High Surgical Risk ◽  
Martin Grade ◽  
Eloquent Cortex ◽  
Grade 3 ◽  
First Line Treatment

Abstract OBJECTIVES Existing studies reporting the risk of surgery for brain arteriovenous malformations (AVMs) are often biased by the exclusion of patients not offered surgery. In this study, we examine the risk of surgery, including cases excluded from surgery because of the high surgical risk. METHODS Data were collected on 640 consecutively enrolled AVMs in a database that included all patients not considered for surgery. RESULTS Patients with Spetzler-Martin grade 1 to 2 AVMs (n = 296) were treated with a surgical risk of 0.7% (95% confidence interval [CI], 0%-3%); patients with Spetzler-Martin grade 3 to 4 AVMs in noneloquent cortex (n = 65) were treated with a surgical risk of 17% (95% CI, 10%-28%). Patients with Spetzler-Martin grade 3 to 5 AVMs in eloquent cortex (n = 168) were treated with a surgical risk of 21% (95% CI, 15%-28%). However, because 14% of patients in this series with similar AVMs were refused surgery because of perceived surgical risk, these results are not generalizable to the population of patients with similar AVMs. CONCLUSION The results of this series suggest that it is reasonable to offer surgery as a preferred treatment option for Spetzler-Martin grade 1 to 2 AVMs. This study also reinforces the predictive value of the Spetzler-Martin grading system, with some caveats.

scholarly journals Current surgical results with low-grade brain arteriovenous malformations

2015 ◽  
Vol 122 (4) ◽  
pp. 912-920 ◽  
Author(s):  
Matthew B. Potts ◽  
Darryl Lau ◽  
Adib A. Abla ◽  
Helen Kim ◽  
William L. Young ◽  
...  
Keyword(s):  
Randomized Trial ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Low Grade ◽  
Cure Rate ◽  
Brain Arteriovenous Malformations ◽  
First Line Therapy ◽  
Delayed Hemorrhage ◽  
Martin Grade

OBJECT Resection is an appealing therapy for brain arteriovenous malformations (AVMs) because of its high cure rate, low complication rate, and immediacy, and has become the first-line therapy for many AVMs. To clarify safety, efficacy, and outcomes associated with AVM resection in the aftermath of A Randomized Trial of Unruptured Brain AVMs (ARUBA), the authors reviewed their experience with low-grade AVMs—the most favorable AVMs for surgery and the ones most likely to have been selected for treatment outside of ARUBA's randomization process. METHODS A prospective AVM registry was searched to identify patients with Spetzler-Martin Grade I and II AVMs treated using resection during a 16-year period. RESULTS Of the 232 surgical patients included, 120 (52%) presented with hemorrhage, 33% had Spetzler-Martin Grade I, and 67% had Grade II AVMs. Overall, 99 patients (43%) underwent preoperative embolization, with unruptured AVMs embolized more often than ruptured AVMs. AVM resection was accomplished in all patients and confirmed angiographically in 218 patients (94%). There were no deaths among patients with unruptured AVMs. Good outcomes (modified Rankin Scale [mRS] score 0–1) were found in 78% of patients, with 97% improved or unchanged from their preoperative mRS scores. Patients with unruptured AVMs had better functional outcomes (91% good outcome vs 65% in the ruptured group, p = 0.0008), while relative outcomes were equivalent (98% improved/unchanged in patients with ruptured AVMs vs 96% in patients with unruptured AVMs). CONCLUSIONS Surgery should be regarded as the “gold standard” therapy for the majority of low-grade AVMs, utilizing conservative embolization as a preoperative adjunct. High surgical cure rates and excellent functional outcomes in patients with both ruptured and unruptured AVMs support a dominant surgical posture for low-grade AVMS, with radiosurgery reserved for risky AVMs in deep, inaccessible, and highly eloquent locations. Despite the technological advances in endovascular and radiosurgical therapy, surgery still offers the best cure rate, lowest risk profile, and greatest protection against hemorrhage for low-grade AVMs. ARUBA results are influenced by a low randomization rate, bias toward nonsurgical therapies, a shortage of surgical expertise, a lower rate of complete AVM obliteration, a higher rate of delayed hemorrhage, and short study duration. Another randomized trial is needed to reestablish the role of surgery in unruptured AVM management.

The transvenous retrograde pressure cooker technique for the curative embolization of high-grade brain arteriovenous malformations

2020 ◽  
pp. neurintsurg-2020-016566
Author(s):  
Masaomi Koyanagi ◽  
Pascal John Mosimann ◽  
Hannes Nordmeyer ◽  
Markus Heddier ◽  
Juergen Krause ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
High Grade ◽  
Transvenous Embolization ◽  
Cure Rate ◽  
Brain Arteriovenous Malformations ◽  
Long Term Follow Up ◽  
Occlusion Rate ◽  
Grade 3

BackgroundTransvenous embolization of brain arteriovenous malformations (AVMs) can be curative. We aimed to evaluate the cure rate and safety of the transvenous retrograde pressure cooker technique (RPCT) using coils and n-butyl-2-cyanoacrylate as a venous plug.MethodsAll AVM patients treated via transvenous embolization between December 2004 and February 2017 in a single center were extracted from our database. Inclusion criteria were: inability to achieve transarterial cure alone; AVM < 3 cm; and single main draining vein. Outcome measures were immediate and 90 days' angiographic AVM occlusion rate, and morbidity and mortality at 30 days and 12 months, according to the modified Rankin Scale (mRS) score.ResultsFifty-one patients (20 women; median age 47 years) were included. A majority (71%) were high grade (3 to 5 in the Spetzler–Martin classification). AVMs were deeply seated in 30 (59%) and cortical in 21 patients (41%). Thirty-three patients were previously embolized transarterially (65%). All patients but one were cured within a single session with the RPCT (96%). Cure was confirmed on follow-up digital subtraction angiography at 3 months in 82% of patients. Three patients experienced intracranial hemorrhage (6%), one requiring surgical evacuation. There were no deaths. One treatment-related major permanent deficit was observed (2.0%). Mean mRS before treatment, at 30 days, and 12 months after RPCT was 1.5, 1.5, and 1.3, respectively.ConclusionsThe retrograde pressure cooker technique can be curative in carefully selected high-grade AVMs. Long-term follow-up and prospective studies are needed to confirm our results.

scholarly journals 878 Comparing Treatment Outcomes for Unruptured Brain Arteriovenous Malformations: A Retrospective Cohort Study

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
B Taweel ◽  
C Gillespie ◽  
T Ali ◽  
A Islim ◽  
C Hannan ◽  
...  
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Arteriovenous Malformations ◽  
Treatment Strategies ◽  
Significant Risk ◽  
Treatment Selection ◽  
Deep Drainage ◽  
Brain Arteriovenous Malformations ◽  
Martin Grade

Abstract Background Unruptured brain arteriovenous malformations (bAVMs) carry a lifetime risk of haemorrhage. Treatment strategies include conservative management, microsurgical excision, endovascular treatment (EVT) and radiosurgery (SRS). Optimal treatment selection remains unclear. Method A single-centre retrospective cohort study of adult unruptured bAVMs (2007-2019). Patients who underwent intervention were propensity matched using baseline features (age, sex, size, deep drainage, eloquence, and Spetzler-Martin grade) with patients conservatively managed. Rates of neurological disability and mortality due to intervention or bleed were compared. Results 137 patients (mean age 48 years [SD = 16], males 64) were included; 34 (25%) EVT, 20 (15%) surgery, 31 (22%) SRS and 51 (37%) conservative. After a median follow-up of 49 months (IQR 23-75), rates of disability were as follows: surgery 35%, EVT 21%, SRS 13% and conservative 8%. Matched cohorts (intervention/conservative) were: surgery-19/18, SRS-30/22 and EVT-33/34. Comparison of disability rates across matched cohorts revealed no statistically significant differences (surgery p = 0.07, SRS p = 0.65 and EVT p = 0.11). Three conservatively managed patients died. Conclusions Unruptured bAVMs carry a significant risk of neurological morbidity, regardless of intervention choice. Treatment choice may have an impact on patient outcomes but requires investigation of stratified cohorts. Findings are consistent with the nuances of AVM treatment selection.

scholarly journals Treatment Outcomes of Unruptured Arteriovenous Malformations With a Subgroup Analysis of ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-Eligible Patients

Neurosurgery ◽  
2015 ◽  
Vol 76 (5) ◽  
pp. 563-570 ◽  
Author(s):  
John D. Nerva ◽  
Alessandra Mantovani ◽  
Jason Barber ◽  
Louis J. Kim ◽  
Jason K. Rockhill ◽  
...  
Keyword(s):  
Randomized Trial ◽  
Functional Outcome ◽  
Scale Score ◽  
Subgroup Analysis ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Low Grade ◽  
Modified Rankin Scale ◽  
Brain Arteriovenous Malformations

Abstract BACKGROUND: The design and conclusions of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial are controversial, and its structure limits analysis of patients who could potentially benefit from treatment. OBJECTIVE: To analyze the results of a consecutive series of patients with unruptured brain arteriovenous malformations (BAVMs), including a subgroup analysis of ARUBA-eligible patients. METHODS: One hundred five patients with unruptured BAVMs were treated over an 8-year period. From this series, 90 adult patients and a subgroup of 61 patients determined to be ARUBA eligible were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades I/II, III, and IV/V was performed. The modified Rankin Scale was used to assess functional outcome. RESULTS: Persistent deficits, modified Rankin Scale score deterioration, and impaired functional outcome occurred less frequently in ARUBA-eligible grade I/II patients compared with grade III to V patients combined (P = .04, P = .04, P = .03, respectively). Twenty-two of 39 patients (56%) unruptured grade I and II BAVMs were treated with surgery without and with preoperative embolization, and all had a modified Rankin Scale score of 0 to 1 at the last follow-up. All patients treated with surgery without and with preoperative embolization had radiographic cure at the last follow-up. CONCLUSION: The results of ARUBA-eligible and unruptured grade I/II patients overall show that excellent outcomes can be obtained in this subgroup of patients, especially with surgical management. Functional outcomes for ARUBA-eligible patients were similar to those of patients who were randomized to medical management in ARUBA. On the basis of these data, in appropriately selected patients, we recommend treatment for low-grade BAVMs.

Abstract TP445: Combined Treatment of Brain Arteriovenous Malformations with Onyx Embolization followed by Radiosurgery

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Laurent Pierot ◽  
Krzysztof Kadziolka ◽  
Olivier Lanoix ◽  
Pascal Rousseaux
Keyword(s):  
Arteriovenous Malformations ◽  
Clinical Status ◽  
Combined Treatment ◽  
Complete Occlusion ◽  
Clinical Complications ◽  
Long Term Follow Up ◽  
Martin Grade ◽  
Grade 3 ◽  
Anatomical Outcome

Purpose: The treatment of cerebral arteriovenous malformations (AVMs) is complex, based on embolization, surgery, and radiosurgery, or a combination of modalities. Treatment by Onyx embolization followed by radiosurgery was not previously evaluated. The goal of our study is to evaluate in an homogeneous, monocentric series the long-term clinical and anatomical outcome of patients treated by this combination. Materials and Methods: From April 2003 to June 2008, 20 patients (11 females and 9 males, aged 10 to 55 years) were treated for a brain AVM by Onyx embolization followed by radiosurgery. AVM size was < 3cm in 7 cases and ≥ 3 cm in 13 cases. Modalities and complications of the procedure were analyzed as well as long term clinical and anatomical outcome (2-4 years after treatment). Results: Out of 17 patients evaluated by DSA after radiosurgery, 10 had a complete occlusion of AVM nidus (58.8%). Complete occlusion was observed in 5/7 Spetzler-Martin grade 1-2 AVMs (71.4%) and in 5/10 Spetzler-Martin grade 3-4 AVM (50.0%). Complete occlusion was observed in 4/5 AVM with size < 3cm (80.0%) and 6/12 AVM with size > 3cm (50.0%). One out of 20 patients had significant worsening of their clinical status (mRS ≥ 2) at long term follow-up. Conclusions: In this series of patients with AVMs treated with Onyx embolization followed by radiosurgery, the safety and efficacy of this treatment combination is quite satisfactory with a 58.8% rate of complete obliteration and a low rate of clinical complications (5.0%).

scholarly journals Angioarchitecture and clinical presentation of brain arteriovenous malformations

2009 ◽  
Vol 67 (2a) ◽  
pp. 316-321 ◽  
Author(s):  
Marcio Luiz Tostes dos Santos ◽  
Zeferino Demartini Júnior ◽  
Luiz Afonso Dias Matos ◽  
Antonio Ronaldo Spotti ◽  
Waldir Antônio Tognola ◽  
...  
Keyword(s):  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Clinical Presentation ◽  
Multivariate Analyses ◽  
Morphological Features ◽  
Feeding Artery ◽  
Focal Neurological Deficit ◽  
Brain Arteriovenous Malformations ◽  
Clinical Presentations ◽  
Martin Grade

The purpose of this study was to correlate the angioarchitecture of brain arteriovenous malformations (AVM) with their clinical presentation. A total of 170 patients with AVM 78 males and 92 females, were studied. Univariate and multivariate analyses were conducted in order to test the associations between morphological features and clinical presentation. The most frequent clinical presentations at diagnosis were hemorrhage in 89 (52%) patients, headache in 79 (46%), focal neurological deficit in 54 (32%), and seizure in 52 (31%). According to the Spetzler-Martin classification, grade I was found in 15 patients, II in 49, III in 55, IV in 41, and grade V in 10 patients. AVM with small nidus size, single feeding artery and single draining vein were associated with hemorrhage. Hemorrhage was positively associated with Spetzler-Martin grade I and negatively with grade V. The association between seizure and large nidus size was positive, however negative with small nidus size.

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