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Orscelik A, Musmar B, Matsukawa H, Ismail M, Elawady SS, Assad S, Cunningham C, Sowlat MM, Spiotta AM. Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01230. [PMID: 38912816 DOI: 10.1227/neu.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
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.
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Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mustafa Ismail
- College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salman Assad
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Kumari K, Arsal SA, Devi A. Letter to the editor: Clinical analysis of surgical outcome of 89 patients having large cerebral arteriovenous malformations. Neurosurg Rev 2024; 47:277. [PMID: 38884809 DOI: 10.1007/s10143-024-02507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/02/2024] [Accepted: 06/08/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Kalpana Kumari
- Dow medical college, Mission road, new labour colony Nanakwara, Karachi city, Sindh, 74200, Pakistan.
| | - Syed Ali Arsal
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75100, Pakistan
| | - Anusha Devi
- Dow medical college, Mission road, new labour colony Nanakwara, Karachi city, Sindh, 74200, Pakistan
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3
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Baranoski JF, Koester SW, Catapano JS, Garcia JH, Pacult MA, Hoglund BK, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Rutledge C, Srinivasan VM, Graffeo CS, Ducruet AF, Albuquerque FC, Lawton MT. Early Treatment of Ruptured Cerebral Arteriovenous Malformations: Analysis of Neurological Outcomes and Health Care Costs. Neurosurgery 2024; 94:212-216. [PMID: 37665224 DOI: 10.1227/neu.0000000000002641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The timing of surgical resection is controversial when managing ruptured arteriovenous malformations (AVMs) and varies considerably among centers. OBJECTIVE To retrospectively analyze clinical outcomes and hospital costs associated with delayed treatment in a ruptured cerebral AVM patient cohort. METHODS Patients undergoing surgical treatment for a ruptured cerebral AVM (January 1, 2015-December 31, 2020) were retrospectively analyzed. Patients who underwent emergent treatment of a ruptured AVM because of acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgical intervention relative to AVM rupture into early (postbleed days 1-20) and delayed (postbleed days 21-180) treatment cohorts. RESULTS Eighty-seven patients were identified. The early treatment cohort comprised 75 (86%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 5 (5) days in the early cohort and 73 (60) days in the delayed cohort ( P < .001). The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation ( P ≥ .15). Follow-up neurological status was equivalent between the cohorts ( P = .65). The associated mean health care costs were higher in the delayed treatment cohort ($241 597 [$99 363]) than in the early treatment cohort ($133 989 [$110 947]) ( P = .02). After adjustment for length of stay, each day of delayed treatment increased cost by a mean of $2465 (95% CI = $967-$3964, P = .002). CONCLUSION Early treatment of ruptured AVMs was associated with significantly lower health care costs than delayed treatment, but surgical and neurological outcomes were equivalent.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
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Bintang AK, Bahar A, Akbar M, Soraya GV, Gunawan A, Hammado N, Rachman ME, Ulhaq ZS. Delayed versus immediate intervention of ruptured brain arteriovenous malformations: A case report. World J Clin Cases 2023; 11:1992-2001. [PMID: 36998967 PMCID: PMC10044944 DOI: 10.12998/wjcc.v11.i9.1992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) remains one of the most prevalent causes of intracranial hemorrhage and stroke-like syndromes in the young adult population. Although it has been agreed upon that definitive treatment using either single or multi-modal approach is warranted for successful bAVM management, much debate still revolves regarding the optimal timing of definitive treatment.
CASE SUMMARY In this report, we present a case of delayed, definitive endovascular treatment for ruptured bAVM in a 21-year-old female, 3 mo post-ictus. The bAVM, with a left pericallosal feeding artery and cortical draining veins, was successfully obliterated through embolization using the Onyx 18. On follow-up the patient has recommenced her daily activities and experiences only mild occasional headaches with mild motor deficits. The report leads to our review on an important issue regarding the optimal timing of ruptured bAVM definitive management and bring forward the current evidence available on delayed vs immediate definitive bAVM intervention. We also highlight current issues that need to be addressed for clearer guidelines on definitive therapy initiation.
CONCLUSION Current treatment paradigms of ruptured bAVM remains elusive, with substantial heterogeneity in the current literature. A consensus on the definition of “acute” vs “delayed”, management goal, follow-up length and outcome parameters are required to support formation of a clear paradigm.
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Affiliation(s)
| | - Ashari Bahar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Muhammad Akbar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Gita Vita Soraya
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Department of Biochemistry, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia
| | - Anthony Gunawan
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Nurussyariah Hammado
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Health and Sport Science, State University of Makassar, Makassar 90222, Indonesia
| | - Mochammad Erwin Rachman
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Medicine, Muslim University of Indonesia, Makassar 90231, Indonesia
| | - Zulvikar Syambani Ulhaq
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency Republic of Indonesia, Cibinong 16911, Indonesia
- Laboratory of Developmental Disorders and Toxicology, Kyushu University, Fukuoka 8190395, Japan
- Department of Biomedical Science, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University, Malang 65144, Indonesia
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Sen RD, Abecassis IJ, Barber J, Levitt MR, Kim LJ, Ellenbogen RG, Sekhar LN. Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations. J Neurosurg 2022; 137:321-328. [PMID: 34861649 DOI: 10.3171/2021.8.jns211075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.
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Affiliation(s)
- Rajeev D Sen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 4Department of Mechanical Engineering, University of Washington, Seattle, Washington; and
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Louis J Kim
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Richard G Ellenbogen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
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Chen Y, Meng X, Ma L, Zhao Y, Gu Y, Jin H, Gao D, Li Y, Sun S, Liu A, Zhao Y, Chen X, Wang S. Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey. Chin Neurosurg J 2020; 6:26. [PMID: 32922955 PMCID: PMC7461270 DOI: 10.1186/s41016-020-00206-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In the benefit of the large population and rapid economic growth, the interventional techniques and equipment for brain arteriovenous malformations (bAVMs) in mainland China have been rapidly improved. Chinese neurosurgical cerebrovascular physicians have accumulated rich experience and made pioneering explorations. This study aims to summarize the experience and treatment progress of bAVMs in mainland China. METHODS We performed a web-based nationwide questionnaire survey among 67 tertiary neurosurgical institutions that had acknowledged treating bAVMs in the primary survey. Our questionnaire included clinical characteristics, radiological findings, intervention indications/contraindications, intervention timing, and intraoperative management of different treatment modalities. RESULTS A total of 63 participants from 49 (73.1%) tertiary neurosurgical institutions responded to our questionnaire. Forty-two (66.7%) were neurosurgeons, 13 (20.6%) were neurointerventionists, and 8 (12.7%) were radiosurgeons. Approximately 3500 to 4000 cases of bAVMs were treated annually in these 49 departments. All participants agreed that the conclusions of ARUBA are debatable. Flow-related aneurysms, deep venous drainage, and arteriovenous fistula were considered as common hemorrhagic risk factors. Unruptured SM IV-V bAVMs, giant bAVMs, pediatric bAVMs, elderly bAVMs, and eloquent bAVMs were not absolute contraindications to intervention. Maximum lesion occlusion and minimal functional impairment were the principles of intervention management. Most of the neurosurgeons and neurointerventionists recommended early intervention (< 30 days) for ruptured bAVMs, and the radiosurgeons suggested intervention in the chronic phase or recovery phase (P < 0.01) and preferably 3 months after bleeding. Multi-modality strategies were thought effective for complex bAVMs, and more exploration of individualized intraoperative management was necessary. CONCLUSIONS Intervention was acceptable for specific selected unruptured bAVMs in mainland China, especially in patients with hemorrhagic risk factors. The application of multidisciplinary cerebrovascular team and multicenter large-sample international registry study might be the next work for Chinese neurosurgical cerebrovascular physicians.
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Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Ye Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
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7
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Deng Z, Chen Y, Ma L, Li R, Wang S, Zhang D, Zhao Y, Zhao J. Long-term outcomes and prognostic predictors of 111 pediatric hemorrhagic cerebral arteriovenous malformations after microsurgical resection: a single-center experience. Neurosurg Rev 2020; 44:915-923. [PMID: 32078085 DOI: 10.1007/s10143-019-01210-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/14/2019] [Accepted: 11/04/2019] [Indexed: 12/19/2022]
Abstract
Comparison in pediatric hemorrhagic arteriovenous malformations (AVMs) to clarify the long-term neurological outcomes and prognostic predictors after surgical intervention was relatively rare, especially in the selection of surgical timing. The objective of this study was to elucidate these points. The authors retrospectively reviewed the pediatric hemorrhagic AVMs resected in their neurosurgical department between March 2010 and June 2017. The natural history was represented by rupture risk. Neurological outcome was assessed with the modified Rankin Scale (mRS) for children. Multivariate logistic regression analyses were used to assess the risk factors for disability (mRS > 2). The hemorrhagic early phase was defined as less than 30 days after bleeding. The corresponding prognosis of different surgical timing (early intervention or delayed intervention) was compared after propensity-score matching (PSM). A total of 111 pediatric hemorrhagic AVM patients were evaluated. The average patient age was 11.1 ± 4.0 years, with a mean follow-up of 4.3 ± 2.1 years. The annualized rupture risk was 9.3% for the pediatric hemorrhagic AVMs, and the annualized re-rupture risk was 9.8%. 7.2% of the patients had disabilities (mRS > 2) and 82.0% achieved neurological deficit-free (mRS < 2) at the last follow-up. Pre-treatment mRS (P = 0.042) and flow-related aneurysms (P = 0.039) were independent factors for long-term disability. In terms of short-term outcomes, early intervention was better than delayed intervention (P = 0.033), but the long-term outcomes were similar between the two groups (P = 0.367). Surgical intervention for pediatric hemorrhagic AVMs is recommended, most of the patients can achieve good neurological outcomes. Moreover, early surgical intervention is preferred after the initial hemorrhage.
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Affiliation(s)
- Zhenghai Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Muir M, Patel R, Gadgil N, Pan I, Lam S. Postoperative 30-day outcomes after craniotomy for supratentorial AVM resection in children. J Clin Neurosci 2019; 70:108-112. [DOI: 10.1016/j.jocn.2019.08.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
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Schuss P, Hadjiathanasiou A, Ilic I, Brandecker S, Güresir Á, Vatter H, Güresir E. Risk of Rebleeding in Patients Suffering From Ruptured Brain Arteriovenous Malformations Undergoing Subacute Treatment: A Single-Center Series and Systematic Review of the Literature. World Neurosurg 2019; 134:e610-e615. [PMID: 31678312 DOI: 10.1016/j.wneu.2019.10.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The optimal timing for treatment of ruptured brain arteriovenous malformation (BAVM) is still controversial. The present study aims to determine safety of subacute BAVM management in clinically stable patients by identifying the rate of rebleeding. METHODS Patients presenting from 2000 to 2018 with ruptured BAVM who were scheduled for BAVM treatment at least 4 weeks after initial hemorrhage were included in the present study. After neurological rehabilitation of the patient and decreased hemorrhage-induced brain swelling, subacute treatment for the ruptured BAVM was carried out. Primary outcome of the present series was defined as treatment failure resulting from rehemorrhage caused by the ruptured BAVM in patients previously labeled eligible for subacute BAVM treatment. Additionally, we performed a systematic review of the contemporary peer-reviewed literature concerning treatment strategy in patients with ruptured BAVM. RESULTS Fifty-five patients suffering from ruptured BAVM were considered eligible for subacute BAVM treatment at our institution. No patient suffered from early rebleeding before definitive BAVM treatment in our institutional group. Our own patient data were then pooled with data from the literature, resulting in 166 patients suffering from ruptured BAVM who underwent subacute BAVM treatment. Of these, 1 patient (0.6%) suffered from rehemorrhage during the recovery period 130 days after initial BAVM rupture. CONCLUSIONS The present series and systematic review revealed a rehemorrhage rate of 0.6% in patients suffering from ruptured BAVM who underwent subacute treatment. Therefore, subacute treatment of patients with ruptured BAVM seems safe after application of rigorous treatment algorithms to sort out patients with higher risk for rehemorrhage.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany.
| | | | - Inja Ilic
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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Hafez A, Oulasvirta E, Koroknay-Pál P, Niemelä M, Hernesniemi J, Laakso A. Timing of surgery for ruptured supratentorial arteriovenous malformations. Acta Neurochir (Wien) 2017; 159:2103-2112. [PMID: 28894970 DOI: 10.1007/s00701-017-3315-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/28/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome. OBJECTIVE To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery. METHODS We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2-4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome). RESULTS Age over 40 years (OR 18.4; 95% CI 1.9-172.1; p = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1-89.2; p = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8-94.4; p = 0.011), and over 400 cm3 bleeding during surgery (OR 11.5; 95% CI 1.5-86.6; p = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6-1524.9; p = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4-829.9; p = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6-332.6; p = 0.007), and over 400 cm3 bleeding during surgery (OR 35.3; 95% CI 1.7-748.7; p = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2-55.7; p = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3-24.3; p = 0.019), and over 400 cm3 bleeding during surgery (OR 5.8; 95% CI 1.2-27.3; p = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome. CONCLUSIONS Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.
| | - Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
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Beecher JS, Lyon K, Ban VS, Vance A, McDougall CM, Whitworth LA, White JA, Samson D, Batjer HH, Welch BG. Delayed treatment of ruptured brain AVMs: is it ok to wait? J Neurosurg 2017; 128:999-1005. [PMID: 28686111 DOI: 10.3171/2017.1.jns16745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.
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Angioarchitectural Risk Factors for Hemorrhage and Clinical Long-Term Outcome in Pediatric Patients with Cerebral Arteriovenous Malformations. World Neurosurg 2016; 89:540-51. [PMID: 26898497 DOI: 10.1016/j.wneu.2016.02.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intracranial arteriovenous malformation (AVM) in children is a rare diagnosis. Little is known about factors determining AVM rupture and appropriate treatment strategies to prevent hemorrhage and associated disability. Available data suggest that children are subject to an increased risk for AVM rupture compared with adults. METHODS In 46 pediatric patients with AVM, demographic factors, clinical presentation, angioarchitectural features, and treatment regimens as well as clinical and radiologic outcomes were retrospectively analyzed. First-line treatment option was microsurgical resection of the disease, with or without preoperative embolization. RESULTS Twenty-four boys (52.2%) and 22 girls (47.8%) with a mean age on admission of 12.4 years (4-18 years) were included. Mean follow-up was 4 years (median, 1.5; range, 0.1-16.4). Thirty-one children presented with intracerebral hemorrhage (67.4%). Small AVMs (<3 cm) ruptured in 83.3% (n = 25) and were shown to be more prone to hemorrhage than larger ones (P < 0.01). Small AVM size (P < 0.01; odds ratio [OR], 0.12; 95% confidence interval [CI] 0.02-0.59) and exclusive deep venous drainage (P < 0.01; OR, 29.74; 95% CI, 2.45-4445.34) were independent risk factors for hemorrhage in the presented cohort. Good long-term outcome was associated with a high score on the Glasgow Coma Scale on admittance (P < 0.05; OR, 0.148; 95% CI, 0.03-0.73). CONCLUSIONS Two-thirds of children with AVM are admitted with intracerebral hemorrhage. Microsurgical resection was successful as confirmed by radiologic studies in 95%, and 79.5% of patients presented in a good clinical condition on follow-up (modified Rankin Scale 0 or 1). Microsurgical treatment is recommended if the lesion is accessible and angioarchitectural risk factors favor definitive treatment.
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