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Natural history and management outcomes of patients with ruptured Spetzler-Martin grade IV and V brain arteriovenous malformations

医学 自然史 放射外科 栓塞 动静脉畸形 颅内动静脉畸形 逻辑回归 改良兰金量表 优势比 外科 脑血管造影 内科学 血管造影 缺血性中风 缺血 放射治疗
作者
Shahab Aldin Sattari,Wuyang Yang,James Feghali,Albert Antar,Alice L. Hung,Risheng Xu,Rafael J. Tamargo,Judy Huang
出处
期刊:Journal of Neurosurgery [American Association of Neurological Surgeons]
卷期号:: 1-9
标识
DOI:10.3171/2024.6.jns241075
摘要

OBJECTIVE The natural history of ruptured high Spetzler-Martin grade IV and V brain arteriovenous malformations (bAVMs) is underreported given the scarcity of this pathology, and decision-making for patients with bAVMs remains unclarified. In this study, the authors sought to shed light on this topic. METHODS Patients harboring ruptured high-grade bAVMs were identified from an institutional database spanning from 1990 to 2020. The authors examined outcomes of annual hemorrhagic risk in natural history and after treatment, follow-up hemorrhage rate, bAVM obliteration, follow-up modified Rankin Scale (mRS) score > 2, worsened mRS score, and mortality. RESULTS After reviewing the charts of 1066 patients without hereditary hemorrhagic telangiectasia, 84 patients with ruptured high-grade bAVMs were included in the study for analysis. For cortical bAVMs, the annual risk of hemorrhage during natural history was 2.68%. Surgery decreased the risk to 0.74%, while radiosurgery increased the risk to 5.35%, and embolization only increased the risk to 16.96%. For deep-seated high-grade bAVMs, the annual risk of hemorrhage during natural history was 8.37%. Radiosurgery decreased the risk to 3.11%, surgery decreased the risk to 5.25%, and embolization only increased the risk to 22.33%. Poisson regression analysis demonstrated that embolization only increased the risk of hemorrhage in cortical bAVMs (rate ratio 4.745, 95% CI 1.365–12.819; p = 0.005) and deep-seated bAVMs (rate ratio 6.290, 95% CI 0.997–21.932; p = 0.013). Logistic regression analysis showed that surgery (OR 52.000, 95% CI 8.083–1046.127; p = 0.004) and radiosurgery (OR 11.142, 95% CI 1.804–217.650; p = 0.029) were predictors of obliteration in cortical and deep-seated bAVMs, respectively. The proportions of patients experiencing a worsened mRS score, a follow-up mRS score > 2, and mortality were similar between conservative and treatment groups. CONCLUSIONS The natural history of cortical ruptured high-grade bAVMs bears a risk similar to that of incidental bAVMs, whereas deep-seated ruptured high-grade bAVMs have an increased risk of hemorrhage. With extremely prudent patient selection, surgery might be a viable option for cortical bAVMs to obliterate the bAVM and reduce hemorrhagic risk, while preserving functional status. Radiosurgery might be beneficial to lower hemorrhagic risk in deep-seated bAVMs. Embolization as a single modality should be avoided as it provides no benefit to reduce hemorrhagic risk.
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