Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes—A Retrospective Study of 25 Cases

Abstract

Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: “early surgery” and “delayed surgery.” The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the “early surgery” group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the “delayed surgery” group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.

Delayed versus immediate intervention of ruptured brain arteriovenous malformations: A case report

“…In this section, we present the current evidence regarding immediate and delayed treatment of bAVMs. Whilst there is currently a lack of studies comparing the two paradigm approaches, we have summarized individual studies looking at either of the two approaches when feasible, with results summarized in Table 1 [ 6 - 15 ]. Traditionally, indications for emergency or immediate intervention of ruptured bAVMs include patients with life-threatening hematoma and its associated mass effects, deteriorating neurological status, and the presence of aneurysms[ 5 , 8 ].…”

“…A recent retrospective study has shown that delayed conclusive treatment yields more favorable functional outcome[ 6 ], and that both approaches are influenced by different factors, wherein early intervention is influenced by the ICH score, while the delayed intervention is influenced by the bAVM microarchitecture as defined by the Spetzler-Martin grades. In said study, the mortality rate between the early and delayed group was also significantly different, although this should be interpreted with caution, due to the higher likelihood of high-risk emergency comorbidities accompanying cases of early treatment.…”

Traffic Patterns of the Migrating Endothelium: How Force Transmission Regulates Vascular Malformation and Functional Shunting During Angiogenic Remodelling

“…Arteriovenous shunts (also referred to as arteriovenous malformations, or AVMs) can pathologically arise in numerous tissues including the liver ( Copel et al, 2018 ), coronary circulation ( Gatzoulis et al, 2018 ), lungs ( Cartin-Ceba et al, 2013 ), and brain ( Principles of Neurological Surgery, 2012 ), often with detrimental effects on health and mortality. In particular, AVMs in the brain are an important cause of haemorrhagic stroke, and surgical treatment options are invasive and limited ( Derdeyn et al, 2017 ; Di Bartolomeo et al, 2021 ). The lack of arteriovenous shunts in healthy vasculature suggests there must be additional mechanisms beyond shear stress which regulate remodelling and prevent shunting, as originally proposed by ( Pries et al, 2010 ).…”