E-032 Preoperative embolization of spetzler martin grade 3 arteriovenous malformations: a multi-center propensity adjusted analysis

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.

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Localization and Microsurgical Resection of Left Postcentral Gyrus Spetzler-Martin Grade 3 Arteriovenous Malformation by Intraoperative Neuronavigation and Tracing of Subcortical Draining Vein: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz383 ◽

2019 ◽

Vol 19 (2) ◽

pp. E185-E186

Author(s):

Qazi Zeeshan ◽

Juan P Carrasco Hernandez ◽

Laligam N Sekhar

Keyword(s):

Arteriovenous Malformation ◽

Blood Clot ◽

Preoperative Embolization ◽

Facial Weakness ◽

Cortical Vein ◽

3 Dimensional ◽

Postcentral Gyrus ◽

Microsurgical Resection ◽

Martin Grade ◽

Grade 3

Abstract This 42-yr-old man presented with a history of sudden right-sided facial and right arm weakness and dysarthria. Head computed tomography showed a left frontal-parietal blood clot. An intra-arterial digital subtraction angiography demonstrated a left subcortical postcentral, Spetzler-Martin Grade 3 arteriovenous malformation (AVM) with a diffuse nidus, measuring 2.1 × 1.5 cm, supplied by branches of the left MCA, and draining into a cortical vein and a deep vein, which was going toward the ventricle. Preoperative embolization was not possible. The patient underwent left frontal-parietal craniotomy with intraoperative motor and sensory mapping. No arterialized veins were visible on the cortical surface. Neuronavigation localized the AVM in the subcortical postcentral gyrus. Through an incision in the postcentral sulcus, microdissection led to a yellowish gliotic plane. The large cortical vein was in the gliotic area and traced to the AVM. Circumferential microdissection was performed around the AVM. It had a very diffuse nidus; the arterial feeders were cauterized and divided, and the superior superficial and inferior deep draining veins were finally occluded, and AVM was removed. Postoperative angiogram showed total removal of the AVM. At discharge, his right arm weakness had improved (power 5/5), and facial weakness and dysarthria were improving (modified Rankin Scale (mRS) 2). At 1-yr follow-up, facial weakness and dysarthria had improved considerably, and patient returned to work (mRS 1). This video shows microsurgical resection of an AVM by neuronavigation and tracing of the subcortical draining vein. The technique of cauterizing the perforating arteries after temporary clipping with flow arrest is shown in the video. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

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Surgery for Unruptured Spetzler-Martin Grade 3 Brain Arteriovenous Malformations

Neurosurgery ◽

10.1227/neu.0000000000000774 ◽

2015 ◽

Vol 77 (3) ◽

pp. 362-370 ◽

Cited By ~ 9

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.

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Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.9.peds146 ◽

2015 ◽

Vol 15 (1) ◽

pp. 71-77 ◽

Cited By ~ 51

Author(s):

Bradley A. Gross ◽

Armide Storey ◽

Darren B. Orbach ◽

R. Michael Scott ◽

Edward R. Smith

Keyword(s):

Arteriovenous Malformations ◽

Neurological Complications ◽

Neurological Deficits ◽

Preoperative Embolization ◽

Recurrence Rates ◽

Microsurgical Treatment ◽

Obliteration Rate ◽

Microsurgical Resection ◽

Martin Grade ◽

Cerebral Avms

OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0–2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.

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

Stroke ◽

10.1161/str.44.suppl_1.atp445 ◽

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%).

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

Neurosurgery ◽

10.1227/01.neu.0000365518.47684.98 ◽

2010 ◽

Vol 66 (3) ◽

pp. 498-505 ◽

Cited By ~ 81

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.

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

World Neurosurgery ◽

10.1016/j.wneu.2017.03.046 ◽

2017 ◽

Vol 102 ◽

pp. 263-274 ◽

Cited By ~ 4

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

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Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

Journal of Neurosurgery ◽

10.3171/jns.2000.93.supplement_3.0096 ◽

2000 ◽

Vol 93 (supplement_3) ◽

pp. 96-101 ◽

Cited By ~ 67

Author(s):

Jong Hee Chang ◽

Jin Woo Chang ◽

Yong Gou Park ◽

Sang Sup Chung

Keyword(s):

Gamma Knife ◽

Arteriovenous Malformations ◽

Gamma Knife Radiosurgery ◽

Maximum Diameter ◽

Content Type ◽

Complete Occlusion ◽

Factors Associated ◽

Martin Grade ◽

Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

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Adenosine-induced Asystole during AVM Embolization

Clinical Neuroradiology ◽

10.1007/s00062-021-01035-z ◽

2021 ◽

Author(s):

V. Hellstern ◽

P. Bhogal ◽

M. Aguilar Pérez ◽

M. Alfter ◽

A. Kemmling ◽

...

Keyword(s):

Demographic Data ◽

Clinical Results ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Residual Shunt ◽

Grade 5 ◽

Martin Grade ◽

Grade 3 ◽

Brain Avms

Abstract Background Adenosine induced cardiac standstill has been used intraoperatively for both aneurysm and arteriovenous malformation (AVM) surgery and embolization. We sought to report the results of adenosine induced cardiac standstill as an adjunct to endovascular embolization of brain AVMs. Material and Methods We retrospectively identified patients in our prospectively maintained database to identify all patients since January 2007 in whom adenosine was used to induce cardiac standstill during the embolization of a brain AVM. We recorded demographic data, clinical presentation, Spetzler Martin grade, rupture status, therapeutic intervention and number of embolization sessions, angiographic and clinical results, clinical and radiological outcomes and follow-up information. Results We identified 47 patients (22 female, 47%) with average age 42 ± 17 years (range 6–77 years) who had undergone AVM embolization procedures using adjunctive circulatory standstill with adenosine. In total there were 4 Spetzler Martin grade 1 (9%), 9 grade 2 (18%), 15 grade 3 (32%), 8 grade 4 (18%), and 11 grade 5 (23%) lesions. Of the AVMs six were ruptured or had previously ruptured. The average number of embolization procedures per patient was 5.7 ± 7.6 (range 1–37) with an average of 2.6 ± 2.2 (range 1–14) embolization procedures using adenosine. Overall morbidity was 17% (n = 8/47) and mortality 2.1% (n = 1/47), with permanent morbidity seen in 10.6% (n = 5/47) postembolization. Angiographic follow-up was available for 32 patients with no residual shunt seen in 26 (81%) and residual shunts seen in 6 patients (19%). The angiographic follow-up is still pending in 14 patients. At last follow-up 93.5% of patients were mRS ≤2 (n = 43/46). Conclusion Adenosine induced cardiac standstill represents a viable treatment strategy in high flow AVMs or AV shunts that carries a low risk of mortality and permanent neurological deficits.

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