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(Stroke. 2005;36:2431.)
© 2005 American Heart Association, Inc.

Original Contributions

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 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.

Correspondence to Andreas Hartmann, MD, Stroke Unit, Department of Neurology, Charité-Hochschulmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany. 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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