Arteriovenous Malformations Spetzler-Martin Grade Research Articles

Cerebral Arteriovenous Malformations Treated With Linear Accelerator Stereotactic Radiosurgery Guided by Magnetic Resonance Imaging and Panangiography: A Latin American Experience

Cerebral arteriovenous malformations (AVM) are vascular lesions that include aberrant communication between arterial and venous systems. Treatment for AVM is still under debate. Surgery, embolization, observation, and radiosurgery are options for patients. Most data for radiosurgery came from the Gammaknife series. However, low middle-income countries have financial constraints to establish dedicated intracranial neurosurgery machines. We aimed to determine AVM obliteration rate in patients treated with linear accelerator stereotactic radiosurgery (SRS) guided by magnetic resonance imaging and panangiography fusion with computed tomography simulation at a quaternary care institution in Latin America.We conducted an observational study with patients treated with SRS at our institution during 2011 and 2017. Exclusion criteria were age younger than 14 and a history of brain cancer. After IRB approval, data were collected retrospectively by reviewing medical records. Patients without available follow-up were contacted to gather missing information. Primary outcome was obliteration rate at 3 years, confirmed by diagnostic imaging (MRI or cerebral panangiography). Secondary outcomes were intracranial bleeding, headaches, epilepsy, and neurological deficits at clinical presentation and after SRS. Analysis included sociodemographic data, AVM characteristics (location and Spetzler-Martin grading), and treatment features. We used descriptive statistics, measures of central tendency and dispersion, and proportions.We included 85 patients. The mean age at treatment was 40.8 (14-73), 49.4% of patients were male, and 50.6% female. The most common location was the frontal lobe in 25.9% (n = 22) and the parietal lobe in 24.7% (n = 21). At diagnosis, 44% of patients had a history of intracranial hemorrhage. 49 patients had received previous embolization. The mean dose of radiosurgery was 19.3 Gy (14-25). The mean isodose was 95.25 (80-98). 35.3% of the patients had an AVM Spetzler-Martin grade 2, 40% grade 3, and 12.9% grade 4. We obtained long-term follow-up data for 42 patients, with a median follow-up of 1366 days. The overall obliteration rate was 60%, based primarily on panangiography (59.1%). Symptoms after SRS included headaches (n = 30) and seizures (n = 10). 2 patients presented intracranial bleeding. We contacted all missing patients, but no follow-up data was available for analysis. Most missing patients lived outside the city.Tri-modality image fusion SRS with linear accelerators for AVM could be a safe and accessible option in low-middle income countries. Health administrator issues, travel distances to access linear accelerators and multidisciplinary teams hinder timely follow-up and surveillance imaging. More prospective data are needed to define the role of SRS for AVMs.V. Rangel: None. J. Cure: None. M. Caicedo-Martinez: None. G. Borda: None. C. Lindado: None. E. Castro-Lombana: None. J. Puentes: None. O. Zorro: None. A. González-Motta: None.

Management strategies for cerebral arteriovenous malformation - An institutional experience

Background: Cerebral Arteriovenous Malformation represent a particularly challenging subset of lesions, given their overall low incidence and the high frequency with which some form of multimodality monitoring may be required for complete obliteration. Materials and Methods: We report retrospective analysis of 9 cases with unruptured cerebral arteriovenous malformation who got admitted in the Banbuntane Hotokokai Hospital, Fujita Health University, and Nagoya, Japan .from the year 2014 to 2017.surgical treatment was appropriate craniotomy and resection based on the location of the arteriovenous malformation with multimodality monitoring with Dual Image Video Angiography, Motor Evoked Potential, and FLOW 800. We studied the following factors: Sex, Age, Arteriovenous Malformation size, Location, occurrence of Intracranial Hemorrhage, Seizure type, Duration of Seizure history, Treatment modality, and Arteriovenous Malformation obliteration. We tested for statistical associations between these factors and seizure presentation and outcomes with Clinical follow-up. Outcome was compared with modified Rankin Scale Results: Out of 9 cases operated for intracranial arteriovenous malformation 5 patients were female and 4 were male. Age [ Mean 39.4 + 16.7] of the patients ranged from 20 to 66 , 5 patients were 25 - 40 and 2 were > 65 and Conclusion: The increasing use of advance imaging techniques will increase the incidence of asymptomatic arteriovenous malformations. Non-ruptured arteriovenous malformation Spetzler Martin Grade 1 or Spetzler Martin Grade 2 have a good outcome for microsurgery [modified Rankin Scale and complete obliteration and there is better outcome with microsurgery.

Microsurgery of Spetzler-Martin Grades III, IV and V Arteriovenous Malformations

Introduction: Brain arteriovenous malformations (AVMs) are congenital complex network of dysplastic vessels and represent challenging neurosurgical pathology. There are many controversies in the literature regarding which is the best treatment for Spetzler-Martin high grade AVMs. Therefore, the authors present their operative experience in thirty-three grade III, IV and V brain AVMs and underline the fundamental role of microsurgery in the treatment of these high-grade AVMs. Material and Method: We retrospectively reviewed medical records of patients with brain AVMs operated from 2009 to 2013 by the same senior neurosurgeon, in “Bagdasar-Arseni” Emergency Clinical Hospital. Results: Fifty patients with brain AVMs underwent surgery. Mean age was 37.58 years, varying from 17 to 73 years. Five patients (10%) had AVMs Spetzler-Martin grade I, 12 patients (24%) grade II, 21 patients (42%) grade III, 7 patients (14%) grade IV and 5 patients (10%) grade V. Forty-three patients (86%) had supratentorial and seven patients (14%) had infratentorial lesions. We included in our study thirty-three grade III, IV and V operated in the Fourth Department of Neurosurgery, Emergency Clinical Hospital Bagdasar-Arseni. The medium age of the patients was 33,6 years. There were 16 men and 17 women. Twenty-four (72,8%) patients presented with ruptured AVM, with various types of intracranial hemorrhage, like: intraparenchymatous hematoma, intraventricular hemorrhage and subarachnoid hemorrhage. There is worth to mention that all posterior fossa arteriovenous malformation presented with hemorrhage at admittance. The rest of the cases, nine cases (27,2%), presented with seizure. The preoperative neurological status of the patients presented with ruptured AVM were worse (medium modified Rankin Score 3,8) compared with patients with unruptured AVM (medium modified Rankin Score 1,6). We performed total resection of AVMs in 29 cases (87,8%). Four patients (12,2%) with arteriovenous malformation located in the eloquent areas of the brain had residual nidus. Patients with residual nidus were referred to stereotactic radiosurgery with good outcome. Twenty-one patients (63,6%) presented increased modified Rankin Score (mRS) following surgery, in 8 cases (24,3%) mRS remained unchanged and 3 patients (9,1%) presented decreased mRS. There was one case of death (3%), a 24 year-old female with a Spetzler-Martin grade V ruptured right temporo-parietal arteriovenous malformation, who presented in emergency with a giant right hemispheric intraparenchimatous hematoma. In that case, the Glasgow Coma Scale at admittance was 5 points and neurological exam revealed acute brainstem dysfunction. Long term follow-up (one year postoperative) showed complete recovery of neurological deficits in all patients with excellent quality of life in 22 patients (66,6%) and good quality of life in 10 cases (30,4%). The seizures remitted completed in 6 patients, while 3 patients required only minimum doses of antiepileptic drugs. The patients who presented with ruptured AVM required after operation only preventive anticonvulsivant therapy for maximum three months.

P-026 Comparative 4D Flow MR Imaging in Quantification of Vascular Haemodynamics in Different Types of Intra-cranial Arteriovenous Malformations

Background and PurposeHaemodynamic characterisation of arteriovenous malformations (AVMs) may have implications for risk stratification. Gross visualisation and quantification of intracranial AVM flow dynamics have been investigated using various methods including...

Patterns of Brain Arteriovenous Malformation Treatment

The extent of variation in the interventional treatment of brain arteriovenous malformations (AVMs) is unknown, so we explored patterns of treatment at 4 neuroscience centers in one European country. We included every participant with an AVM in a prospective, population-based cohort study of adults aged >or=16 years residing in Scotland at the time of AVM diagnosis in 1999 to 2003. Only 11 (5%) of the 229 adults were not managed at a neuroscience center. Adults who received interventional treatment were younger (median, 43 versus 54 years), more likely to have presented with hemorrhage (OR, 2.8; 95% CI, 1.6 to 4.9), and had smaller AVMs (median nidus diameter, 2 cm versus 3 cm; P=0.003) than those who did not. Adults seen at the 4 centers only differed in AVM Spetzler-Martin grade (P=0.04). The 4 centers did not differ in the proportion of adults with AVMs who received interventional treatment (P=0.16), but they differed in the Spetzler-Martin grade of the AVMs they treated (Grades III to IV, P=0.01) and the interventional treatments used (P=0.004). The 2 largest centers differed from each other in the likelihood of surgical resection (OR, 0.2; 95% CI, 0.1 to 0.6) and stereotactic radiosurgery (OR, 2.8; 95% CI, 1.3 to 6.1), and the choice of modality varied within some Spetzler-Martin grades. Patient characteristics and patterns of AVM interventional treatment differ between neuroscience centers in the same population necessitating careful consideration of these factors when comparing one hospital's outcome with another.

Risk of Hemorrhage and Obliteration Rates of LINAC-Based Radiosurgery for Cerebral Arteriovenous Malformations Treated After Prior Partial Embolization

We investigate patient outcome, risk of hemorrhage, and factors affecting obliteration after LINAC-based radiosurgery (RS) for cerebral arteriovenous malformations (AVM) treated after partial embolization. This analysis is based on 50 patients treated after prior embolization. According to the Spetzler-Martin criteria the AVM classification was as follows: 9 patients, Grade I (18%); 19, Grade II (38%); 18, Grade III (36%); and 4, Grade IV (8%). Median RS-based AVM score was 1.41. Median single dose was 18 Gy/ 80% isodose (range, 15-22 Gy) and median AVM volume was 4.0 cc (range, 0.2-22.6 cc). In all, 34 patients (68%) experienced hemorrhage before RS. Median follow-up was 3.1 year (range, 8.5 months to 15 years). Actuarial complete obliteration rate was 67% after 3 years and 78% after 4 years. The complete obliteration rate was significantly higher in AVM <3 cm (92% vs. 60%, p < 0.01) and in AVM Spetzler-Martin Grade I/II (90% vs. 59%, p < 0,01). Intracranial hemorrhage after RS was seen in 6 patients (12%) after 8.5 months median. Annual bleeding risk was 7.9% after 1 year and 2.2% after 2 years. It was found that AVM diameter > or =3 cm (p < 0.006), AVM volume > or =4 cc (p < 0.01), AVM score > or =1.5 (p < 0.03), and single dose <18 Gy (p < 0.03) were associated with a significant higher bleeding risk. The rate of obliteration after RS in AVM treated after prior partial embolization depends on size as well as Spetzler-Martin grade. The risk of intracranial hemorrhage is not increased after RS and depends on AVM score, size, and volume, as well as on applied single dose.