Ruptured cerebral arteriovenous malformations: Outcomes analysis after microsurgery

Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT).

METHOD

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision.

RESULTS

MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01).

CONCLUSION

This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.

Postoperative Neurological Complications after a Cranial Surgery: A Multicentre Prospective Observational Study

Background  Cranial surgery is associated with multiple postoperative complications varying from simple nausea and vomiting to devastating complications such as stroke and death. This multicentre collaborative effort was envisioned to collect observational data regarding postoperative complications in cranial surgeries among the Indian population. The aim of this study was to describe the postoperative neurological complications occurring within the first 24 hours after surgery and to identify the predictive factors.

Methods Data was collected from three participating tertiary care academic institutions. The study was prospective, observational, multicentre design with data collected over a period of two months or 100 cases, whichever is earlier, from each participating institute. A predesigned Microsoft excel sheet was distributed among all three centers to maintain uniformity. All patients aged 18 years and above of both sexes undergoing elective or emergency craniotomies were included in the study. The postoperative neurological complications (within 24 hours) assessed were: (1) Neurological deficit (ND) defined as new focal neurological motor deficit relative to preoperative status. (2) Sensorium deterioration (SD) defined as reduction in Glasgow coma score (GCS) by 2 or more points compared with preoperative GCS. (4) Postoperative seizures (SZs) defined as any seizure activity. All possible variables associated with the above neurological complications were tested using Chi-square/Fisher exact test or Mann–Whitney U test. The predictors, which were statistically significant at p < 0.2, were entered into a multiple logistic regression model. Alpha error of 5% was taken as significant.

Results Data from three institutions was collected with a total of 279 cases. In total, there were 53 (19%) neurological complications. There were 28 patients with new postoperative NDs (10.04%), 24 patients had SD (8.6%), and 17 patients had seizures (6.1%). Neurological deficits were significantly less in institution 2. Diagnosis of traumatic brain injury (TBI) was associated with very low risk of ND, and vascular pathology was associated with higher chance of a ND. The duration of anesthesia was found to be significantly predictive of SD (OR/CI = 1.01 / 1–1.02). None of the factors were predictive of PS.

Conclusion The incidences of postoperative ND, SD and postoperative seizures were 10%, 8.6%, and 6.1%, respectively. Studies with a much larger sample size are required for a better and detailed analysis of these complications.

Incidence of Spontaneous Obliteration in Untreated Brain Arteriovenous Malformations

BACKGROUND

Spontaneous obliteration (SpO) of untreated arteriovenous malformations (AVMs) is rare with fewer than 100 cases reported. The incidence and predisposing factors of SpO remain unclear, impeding our understanding of lesion progression in untreated patients.

OBJECTIVE

To determine the incidence rate and predisposing factors of SpO in a North American cohort.

METHODS

AVMs were retrospectively evaluated at our institution for over 25 yr. Untreated AVMs were divided into 2 groups: SpO-AVMs and non-SpO-AVMs. All statistical results were based on univariate analyses. Incidence was generated from counts of SpO over the untreated interval in patient years from birth until obliteration, treatment, or last follow-up.

RESULTS

One hundred fifty-four patients had untreated AVMs; SpO was observed in 4. Average ages were 49.0 ± 23.6 and 48.7 ± 20.4 yr in the SpO-AVM and non-SpO-AVM group, respectively (P = .98). Average AVM sizes were 2.0 ± 1.8 cm (SpO-AVMs) and 3.7 ± 2.6 cm (non-SpO-AVMs, P = .25). All SpO-AVMs and 40 (27.0%) non-SpO-AVMs had a ruptured presentation (P = .006). A single draining vein was observed in all SpO-AVMs and 39 (32.8%) non-SpO-AVMs (P = .01). Deep venous drainage was not observed in any SpO-AVMs, but in 81 (57.9%) non-SpO-AVMs (P = .04). Mean follow-up time was 37.0 ± 42.6 and 75.6 ± 161.7 mo in SpO-AVM and non-SpO-AVMs patients, respectively. Of the 2 SpO-AVM patients with postobliteration follow-up, 1 experienced recanalization. From a 672-patient cohort, the incidence of SpO over 28 961 patient years was 0.014%.

CONCLUSION

SpO-AVMs have an annual incidence rate of approximately 0.014% and tend to present with rupture, a single draining vein, and superficial venous drainage. Expectation of SpO for untreated AVMs is not justified, and patients should anticipate life-long hemorrhagic risk for untreated AVMs.

Cerebrovascular Imaging: Which Test is Best?

Optimal diagnosis and characterization of cerebrovascular disease requires selection of the appropriate imaging exam for each clinical situation. In this review, we focus on intracranial arterial disease and discuss the techniques in current clinical use for imaging the blood vessel lumen and blood vessel wall, and for mapping cerebral hemodynamic impairment at the tissue level. We then discuss specific strategies for imaging intracranial aneurysms, arteriovenous malformations, dural arterial venous fistulas, and arterial steno-occlusive disease.

Complicações pós-operatórias em neurocirurgia eletiva e não eletiva

Resumo Objetivo Avaliar a incidência de complicações pós-operatorias e mortalidade entre pacientes submetidos a neurocirurcia eletiva e não eletiva. Metodos Estudo de coorte prospectivo com pacientes adultos, acompanhados desde o período pré-operatório até a alta hospitalar ou óbito. Resultados Foram incluídos 127 pacientes no grupo cirúrgico eletivo e 75 pacientes no grupo cirúrgico não eletivo. O grupo eletivo teve mais vômitos (p=0,010) e dor (p<0,001) e o grupo não eletivo apresentou mais hipertensão intracraniana (p=0,001), anisocoria (p=0,002), vasoespasmo cerebral (p=0,043), pupilas não fotorreagentes (p=0,006) e reoperação (p=0,046). A taxa de mortalidade foi de 5,5% no grupo de cirurgia eletiva e 26,7% no grupo de cirurgia não eletiva (p<0,001). Conclusão Os procedimentos eletivos em neurocirurgia estão relacionados a maior frequência de complicações sistêmicas, enquanto as cirurgias não eletivas tiveram taxas significativamente mais altas de complicações neurológicas e mortalidade.