Published Online
on October 13, 2005

A more recent version of this article appeared on November 1, 2005

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Submitted on July 7, 2005
Revised on August 11, 2005
Accepted on August 19, 2005

Determinants of Staged Endovascular and Surgical Treatment Outcome of Brain Arteriovenous Malformations

Andreas Hartmann MD^*; Henning Mast MD; Jay P. Mohr MD; John Pile-Spellman MD; E. Sander Connolly MD; Robert R. Sciacca EngScD; Alexander Khaw MD; and Christian Stapf MD

From the Doris and Stanley Tananbaum Stroke Center (A.H., H.M., A.K., C.S., J.P.M.), Neurological Institute, Columbia University College of Physicians and Surgeons, New York, NY; the Stroke Unit, Department of Neurology (A.H.), Charité-Campus Benjamin Franklin, Berlin, Germany; Schlaganfallzentrum Halle (H.M.), Berufsgenossenschaftliche Kliniken, Bergmannstrost, Halle, Germany; the Departments of Interventional Neuroradiology (J.P.-S.), Neurological Surgery (E.S.C.), and Medicine (R.R.S.), Columbia University College of Physicians and Surgeons, New York, NY; Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY; the Department of Neurology (A.K.), Ernst Moritz Arndt-University, Greifswald, Germany; and the Department of Neurology (C.S.), Hôpital Lariboisière, Paris, France.

^* To whom correspondence should be addressed. E-mail: ahart{at}zedat.fu-berlin.de.

Background and Purpose--Therapy of brain arteriovenous malformations (AVMs) often requires the combination of different treatment modalities. Independently assessed data on neurologic outcome after multidisciplinary AVM therapy are scarce.

Methods--The 119 consecutive patients (49% women, mean age 34±13 years) with brain AVMs receiving endovascular embolization followed by surgical treatment were analyzed. Neurologic impairment was assessed prospectively by a neurologist using the modified Rankin Scale (mRS) before, during, and after completed AVM therapy. The association of demographic, clinical, and morphologic characteristics with new treatment-related neurologic deficits was calculated.

Results--The 119 patients were treated with 240 superselective embolizations (median, 2; range, 1 to 8) using n-butyl cyanoacrylate. Mean follow-up time after surgery was 9.6±13.2 months. On the Spetzler-Martin scale, 8% of the AVMs were grade 1, 27% grade 2, 40% grade 3, 22% grade 4, and 3% grade 5. Disabling treatment-related complications (mRS3) occurred in 5% (95% confidence interval [CI], 1% to 9%) of the patients. Nondisabling new deficits were observed in another 42% (95% CI, 33% to 51%). No patient died. Nonhemorrhagic AVM presentation (odds ratio [OR], 5.00; 95% CI, 1.75 to 14.29), deep venous drainage (OR, 3.09; 95% CI, 1.43 to 6.64), AVM location in an eloquent brain region (OR, 2.42; 95% CI, 1.10 to 5.33), and large AVM size (OR, 1.05; 95% CI, 1.01 to 1.09) were independently associated with new treatment-related deficits.

Conclusions--Our results suggest an increased treatment risk for patients with previously unbled AVMs from combined endovascular and surgical AVM therapy. Additional risk factors for treatment-related neurologic deficits may be large AVM size, deep venous drainage, and AVM location in eloquent brain regions.

Key words: AVM • brain arteriovenous malformation • embolization • outcome • surgery

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