Differences in Functional Outcome Across Subtypes with Spetzler-Martin Grade II Arteriovenous Malformations

Hung, Alice L.; Yang, Wuyang; Westbroek, Erick M.; Garzón-Muvdi, Tomás; Caplan, Justin M.; Braileanu, Maria; Wang, Joanna Y.; Colby, Geoffrey P.; Coon, Alexander L.; Tamargo, Rafael J.; Huang, Judy

doi:10.1093/neuros/nyw140

Cited by 11 publications

(9 citation statements)

References 36 publications

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“…In this study, we found that (1) microsurgical resection of both ruptured and unruptured SM I-II AVMs is safe and results in complete angiographic cure; (2) adjunctive presurgical embolization carries low morbidity; and, (3) clinical deficits immediately after embolization or microsurgery are transient and often improve or resolve over time. Our results are consistent with the results of other large published case series on the surgical outcome of low-grade AVMs 10–13…”

Section: Discussionsupporting

confidence: 92%

“…Similar to the heterogeneity within SM grade III AVMs, there is heterogeneity within SM grade II AVMs. In their study of functional outcomes across different subtypes of 208 SM grade II AVMs, Hung et al found that deep venous draining SM grade II AVMs had a worse outcome than medium sized grade II AVMs and eloquently located grade II AVMs 10. Similarly, Schaller et al showed that 29.5% of patients with deep drainage had permanent post-treatment deficits compared with 7.5% patients with superficial drainage 18.…”

Section: Discussionmentioning

confidence: 99%

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Curative treatment for low-grade arteriovenous malformations

Wang

Mandigo

Feldstein

et al. 2019

J NeuroIntervent Surg

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BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Curative treatment for low-grade arteriovenous malformations

Wang

Mandigo

Feldstein

et al. 2019

J NeuroIntervent Surg

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“…The study concluded that Group 1 (S2V0E0) patients had the best functional outcome gain from treatment, whereas Group 3 (S1V1E0) patients fared less well, particularly with surgical treatment. [29]…”

Section: Methodsmentioning

confidence: 99%

Expert consensus on the management of brain arteriovenous malformations

Kato

Dong²,

Chaddad-Neto

et al. 2019

Asian J Neurosurg

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Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the "Expert Consensus on the Management of Brain Arteriovenous Malformations".

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“…The wide heterogeneity of AVMs with respect to their size, anatomy, location, and patient characteristics further complicates the surgical decision-making process. 7,9,14 In recent decades, numerous classification schemes have been developed to predict the risks of AVM treatment. 4,5,16,19,22,23,25,26,28,30 Grading systems can be helpful by inviting the educated clinical gestalt of operative risk by a surgeon to be compared to an objective number that summarizes known risk factors based on large sample sizes.…”

Section: Discussionmentioning

confidence: 99%

“…20 Together, these studies suggest that size may be the most important factor among grade III AVMs. Most recently, Hung et al performed the same analysis for grade II AVMs and found that the S2V0E0 subtype had the best outcome, whereas the S1V1E0 sub-type had the worst outcome, 9 suggesting that deep venous drainage portends a worse outcome than eloquence for grade II AVMs. Even with numerous grading scales in hand, it has been shown in an online survey that there is wide variation in clinicians’ opinions on which patient and/or AVM characteristics are most important for decisions regarding treatment or trial enrollment.…”

Section: Discussionmentioning

confidence: 99%

Does eloquence subtype influence outcome following arteriovenous malformation surgery?

Yoon

Cole

Kim

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Although numerous arteriovenous malformation (AVM) grading scales consider eloquence in risk assessment, none differentiate the types of eloquence. The purpose of this study was to determine if eloquence subtype affects clinical outcome. METHODS This is a retrospective review of a prospectively collected clinical database of brain AVMs treated with microsurgery in the period from 1997 to 2017. The only inclusion criterion for this study was the presence of eloquence as defined by the Spetzler-Martin grading scale. Eloquence was preoperatively categorized by radiologists. Poor outcome was defined as a modified Rankin Scale (mRS) score 3–6, and worsening clinical status was defined as an increase in the mRS score at follow-up. Logistic regression analyses were performed. RESULTS Two hundred forty-one patients (49.4% female; average age 33.9 years) with eloquent brain AVMs were included in this review. Of the AVMs (average size 2.7 cm), 54.4% presented with hemorrhage, 46.2% had deep venous drainage, and 17.0% were diffuse. The most common eloquence type was sensorimotor (46.1%), followed by visual (27.0%) and language (22.0%). Treatments included microsurgery alone (32.8%), microsurgery plus embolization (51.9%), microsurgery plus radiosurgery (7.9%), and all three modalities (7.5%). Motor mapping was used in 9% of sensorimotor AVM cases, and awake speech mapping was used in 13.2% of AVMs with language eloquence. Complications occurred in 24 patients (10%). At the last follow-up (average 24 months), 71.4% of the patients were unchanged or improved and 16.6% had a poor outcome. There was no statistically significant difference in the baseline patient and AVM characteristics among the different subtypes of eloquence. In a multivariate analysis, in comparison to visual eloquence, both sensorimotor (OR 7.4, p = 0.004) and language (OR 6.5, p = 0.015) eloquence were associated with poor outcomes. Additionally, older age (OR 1.31, p = 0.016) and larger AVM size (OR 1.37, p = 0.034) were associated with poor outcomes. CONCLUSIONS Unlike visual eloquence, sensorimotor and language eloquence were associated with worse clinical outcomes after the resection of eloquent AVMs. This nuance in AVM eloquence demands consideration before deciding on microsurgical intervention, especially when numerical grading systems produce a score near the borderline between operative and nonoperative management.

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Differences in Functional Outcome Across Subtypes with Spetzler-Martin Grade II Arteriovenous Malformations

Abstract: Subtypes of grade II AVMs portend different posttreatment gains in functional outcome. Group 1 (S2V0E0) patients had the best functional outcome gain from treatment, while group 3 (S1V1E0) patients fared less well, particularly with surgical treatment.

Cited by 11 publications

References 36 publications

Curative treatment for low-grade arteriovenous malformations

Curative treatment for low-grade arteriovenous malformations

Expert consensus on the management of brain arteriovenous malformations

Does eloquence subtype influence outcome following arteriovenous malformation surgery?

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