Outcome of Microsurgery for Arteriovenous Malformations in a Resource-Restricted Environment: Single-Surgeon Series from Vietnam

Abstract

The health care expenditure in Vietnam is equivalent to 1% of that in the United States. For most patients with brain arteriovenous malformations (AVM), surgery is the only available treatment modality. This study reports on the outcomes on AVM microsurgery in this resource-restricted environment. This is a prospectively collected, retrospectively analyzed case series of consecutive patients who underwent surgical resection of AVM by a single surgeon in Vietnam. All surgeries were performed in a 3-year period in Hanoi. The primary endpoints were obliteration of the AVM and surgical morbidity (modified Rankin Scale [mRS] > 1). There were 86 patients and 62% presented with hemorrhage. Only 2 patients had preoperative embolization, and 47 patients (54%) had preoperative digital subtraction angiography. All patients underwent microsurgical resection of their AVM. Excluding the 4 patients who died, the AVM obliteration rate was 98%. The mean follow-up was 20.1 months. Before surgery, 36% of patients had at least some disability (mRS > 1). Postoperatively, this was reduced to 10% (McNemar P= 0.007). For the overall cohort, neurologic status was improved from initial encounter to final assessment (P= 0.001). Because of resource restrictions, some patients with hemorrhage experienced delays in treatment. There was no difference in outcome between patients who were admitted before or after 24 hours post ictus (P= 0.6). The days spent waiting for surgery did not correlate with final mRS in univariate regression (R2= 0.01). Notwithstanding the limitation in health care resources in Vietnam, surgery for AVMs was successful in eliminating the malformation, with obliteration rates and morbidity comparable with international standards.