Microsurgical resection of Spetzler–Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management—results of a single group series

Steiger, Hans‐Jakob; Fischer, Igor; Rohn, Benjamin; Turowski, Bernd; Etminan, Nima; Hänggi, Daniel

doi:10.1007/s00701-015-2474-9

Cited by 25 publications

(25 citation statements)

References 32 publications

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“…The interdisciplinary management of AVM during the pertinent period has been described elsewhere [23,25]. In short, options offered to the patients at that period included endovascular embolization, microsurgery, and Gamma Knife radiosurgery.…”

Section: Methodsmentioning

confidence: 99%

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Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature

et al. 2016

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Although the benefit of intervention for unruptured arteriovenous malformation (AVM) with regard to stroke rates and long-term disability remains unclear, most patients present with symptoms, such as epilepsy, headache, or neurological deficits, compromising their quality of life. Detailed analysis of the long-term effects of microsurgical treatment on quality of life, epilepsy, and headache was the purpose of this audit. A series of 25 microsurgically treated patients were interviewed on average 7 ± 5 years after treatment. Detailed information was obtained regarding frequency and severity of seizures and headaches. Outcome data was compared with the initial complaints and neurological findings. The Short Form (SF)-36 was used to assess health-related quality of life. On average, the SF-36 scores did not differ significantly from the age-matched German norm values. Patients suffering from chronic headache prior to treatment scored worse in most SF-36 subscales than patients without headache at the time of treatment, and the difference was significant in the SF-36 dimensions physical role functioning and emotional role functioning (P = 0.04). In contrast, there was a trend for patients treated for incidental AVM to score somewhat better than the age norm. Twelve patients had been admitted with epilepsy. At the time of follow-up, all patients were seizure free (Engel class I), although 7 of them continued to take antiepileptic medication. Two of 13 patients without epilepsy at the time of treatment experienced seizures sometime during the post treatment course and were under medication at the time of long-term follow-up interview. At the time of the audit, 7 of 11 patients admitted with chronic headache necessitating regular use of pain medication indicated not to use pain medication any longer. Our data suggest that initial symptoms leading to diagnosis and treatment of unruptured AVM may influence long-term quality of life following treatment. Patients admitted with headache as the chief complaint appear to fare worse than patients with epileptogenic or incidental AVMs.

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Section: Methodsmentioning

confidence: 99%

“…Wang recently reported a somewhat less positive view of their results[25]. Of the 49 patients (30 %) presenting with seizures, 60.4 % experienced seizure persistence after treatment.…”

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confidence: 97%

Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature

et al. 2016

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“…According to Bervini et al [2], the time to benefit from surgery of an unruptured bAVM should occur within 5 years of diagnosis for Spetzler-Ponce class A; it may occur but will be more than 8 years for Spetzler-Ponce class B and will never occur for Spetzler-Ponce class C. Steiger et al also demonstrated that microsurgical removal of unruptured Spetzler-Martin grade 1 and 2 AVMs produced more favorable long-term results than the modeled natural history, while surgical treatment of Spetzler-Martin grades 3 and 4 AVM did not [20].…”

Section: Treatmentmentioning

confidence: 99%

“…Furthermore, younger age may confer a certain advantage with respect to recovery from postoperative neurological deficits. Steiger et al demonstrated that patients younger than 39 years tended to fare better after microsurgical treatment than older patients [20].…”

Section: Treatmentmentioning

confidence: 99%

To treat or not to treat brain AVMs—that’s still the question

Meling

2017

Acta Neurochir

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“…Especially in the presence of deep venous AVM drainage and/or eloquent AVM location the natural risk for rupture amounts to 35-38% within 8 years of simple observation! Some unicentric and retrospective clinical series have shown that already [1][2][3][4][5], but with their detailed analysis of potential risk factors for rupture, the authors provide further evidence for those doctors who are involved in the decisionmaking process when it comes to patient counseling, which should be based on hard facts rather than on gut feelings, of course. Therefore, they provide an analysis of existing tools to assess the rupture risk of AVM by a simple mathematical formula, and clinical tools, such as the Spetzler-Ponce classification, or the more recently introduced Lawton-Young score for the estimation of surgical risk.…”

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confidence: 91%

To treat, or not to treat, that is the question: Critical review of brain AVM surgery, surgical results and natural history in 2017 by Michael Morgan et al.

Schaller

Steiger

2017

Acta Neurochir

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This extensive review of the results of surgical management of cerebral arteriovenous malformations (bAVMs) as compared to sole observation comes from one of the most experienced groups of AVM surgeons, who have made seminal contributions to the understanding of AVM pathophysiology throughout the past three decades.In analyzing angioarchitectural features and the natural evolution of AVM in large observational patient series, Morgan et al. arrive at the affirmation of what most neurovascular surgeons are using as criteria to judge an AVM's risk for rupture for many years already. However, rarely it has been written so clearly and rarely was it based on such hard data from longitudinal observational studies. In fact, this teaches us a lot about the potential danger of certain AVM. It is obvious that not all unruptured AVM should be treated (surgically). It is not that simple, and experienced and thoughtful neurosurgeons do not use such simplistic views either. But those patients, whose AVM are classified as Ponce A, will do a lot better when undergoing removal of that AVM rather than letting the natural course decide over the patient's fate. Especially in the presence of deep venous AVM drainage and/or eloquent AVM location the natural risk for rupture amounts to 35-38% within 8 years of simple observation! Some unicentric and retrospective clinical series have shown that already [1][2][3][4][5], but with their detailed analysis of potential risk factors for rupture, the authors provide further evidence for those doctors who are involved in the decisionmaking process when it comes to patient counseling, which should be based on hard facts rather than on gut feelings, of course. Therefore, they provide an analysis of existing tools to assess the rupture risk of AVM by a simple mathematical formula, and clinical tools, such as the Spetzler-Ponce classification, or the more recently introduced Lawton-Young score for the estimation of surgical risk. Altogether, they are liberating us in a scientifically sound manner from the myths of the ARUBA study. That study has never examined the results of surgical treatment of cerebral AVM, but is falsely taken as the main reference in favor of conservative treatment by so many not only neurologists and GPs but by many of the young generation of neurosurgeons as well. If there is something the neurosurgical community has to be blamed for, then it is the fact that we have never reached out to a wider community with our efforts to report the good results that can be achieved by surgical removal of certain AVM as compared to a waitand-see strategy. We have never achieved to launch a highlevel RCT on surgical vs. conservative treatment of cerebral AVM. Nobody else, except ourselves, the neurosurgical community, can be accused for the fact that we have let others with lesser understanding and expertise in the field of cerebral AVM influence the opinion of a wider medical community-by journal impact factor rather than by evidence-and to conduct a study, which had lead to fundamental ...

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Microsurgical resection of Spetzler–Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management—results of a single group series

Abstract: Microsurgically managed SM grades 1 and 2 fared better than the modeled natural course but grades 3 and 4 AVM did not benefit from surgery. Younger patients appear to fare more favorably than older patients.

Cited by 25 publications

References 32 publications

Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature

Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature

To treat or not to treat brain AVMs—that’s still the question

To treat, or not to treat, that is the question: Critical review of brain AVM surgery, surgical results and natural history in 2017 by Michael Morgan et al.

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