Skip to main content
Erschienen in: Acta Neurochirurgica 8/2015

01.08.2015 | Clinical Article - Vascular

Microsurgical resection of Spetzler–Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management—results of a single group series

verfasst von: Hans-Jakob Steiger, Igor Fischer, Benjamin Rohn, Bernd Turowski, Nima Etminan, Daniel Hänggi

Erschienen in: Acta Neurochirurgica | Ausgabe 8/2015

Einloggen, um Zugang zu erhalten

Abstract

Background

The therapeutic benefits of microsurgery for unruptured brain AVM remain unclear.

Methods

A series of 97 microsurgically resected unruptured brain AVM was analyzed in terms of postoperative morbidity and lifetime loss of quality-adjusted life-years (QALY). For comparison, the natural risk of becoming disabled was modeled on the basis of published data.

Results

Discharge morbidity was recorded in 11 of the 69 of Spetzler–Martin (SM) grade 1 and 2 AVMs (16 %), eight of 22 (36 %) grade 3, and four of six grade 4 (67 %), permanent morbidity >mRS 1 in 3 (4.3 %) grade 1 and 2, four (18 %) grade 3, and three (50 %) grade 4. Treatment inflicted loss of QALY amounted to 0.5 years for SM grade 1–2, 2.5 years grade 3, 7.3 years for grade 4. For the SM grades 1 and 2, the treatment-related loss of 0.5 QALY was met by the natural course after 2.7–4.3 years. For the Spetzler–Martin grades 3 and 4, the treatment-induced loss QALY was not met by the natural risk within a foreseeable time. Permanent morbidity and treatment inflicted loss of QALY of patients younger than 39 years was lower than that of older patients (7 vs. 15 % and 1.0 vs. 2.1 QALY).

Conclusions

Microsurgically managed SM grades 1 and 2 fared better than the modeled natural course but grades 3 and 4 AVM did not benefit from surgery. Younger patients appear to fare more favorably than older patients.
Literatur
1.
Zurück zum Zitat Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP, Scottish Audit of Intracranial Vascular Malformations Collaborators (2014) Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 311(16):1661–1669CrossRefPubMed Al-Shahi Salman R, White PM, Counsell CE, du Plessis J, van Beijnum J, Josephson CB, Wilkinson T, Wedderburn CJ, Chandy Z, St George EJ, Sellar RJ, Warlow CP, Scottish Audit of Intracranial Vascular Malformations Collaborators (2014) Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 311(16):1661–1669CrossRefPubMed
2.
Zurück zum Zitat Bervini D, Morgan MK, Ritson EA, Heller G (2014) Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. J Neurosurg 121(4):878–890CrossRefPubMed Bervini D, Morgan MK, Ritson EA, Heller G (2014) Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. J Neurosurg 121(4):878–890CrossRefPubMed
3.
Zurück zum Zitat Bervini D, Morgan MK, Ritson EA, Heller G (2014) Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. Neurochirurgie 60(6):327CrossRef Bervini D, Morgan MK, Ritson EA, Heller G (2014) Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. Neurochirurgie 60(6):327CrossRef
4.
Zurück zum Zitat Blicher JU, Nielsen JF (2008) Does long-term outcome after intensive inpatient rehabilitation of acquired brain injury depend on etiology? NeuroRehabilitation 23(2):175–183PubMed Blicher JU, Nielsen JF (2008) Does long-term outcome after intensive inpatient rehabilitation of acquired brain injury depend on etiology? NeuroRehabilitation 23(2):175–183PubMed
5.
Zurück zum Zitat Brown RD Jr, Wiebers DO, Forbes G, O’Fallon WM, Piepgras DG, Marsh WR, Maciunas RJ (1988) The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68(3):352–357CrossRefPubMed Brown RD Jr, Wiebers DO, Forbes G, O’Fallon WM, Piepgras DG, Marsh WR, Maciunas RJ (1988) The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68(3):352–357CrossRefPubMed
6.
Zurück zum Zitat Choi JH, Mast H, Sciacca RR, Hartmann A, Khaw AV, Mohr JP, Sacco RL, Stapf C (2006) Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation. Stroke 37(5):1243–1247CrossRefPubMed Choi JH, Mast H, Sciacca RR, Hartmann A, Khaw AV, Mohr JP, Sacco RL, Stapf C (2006) Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation. Stroke 37(5):1243–1247CrossRefPubMed
7.
Zurück zum Zitat Crawford PM, West CR, Chadwick DW, Shaw MD (1986) Arteriovenous malformations of the brain: natural history in unoperated patients. J Neurol Neurosurg Psychiatry 49(1):1–10PubMedCentralCrossRefPubMed Crawford PM, West CR, Chadwick DW, Shaw MD (1986) Arteriovenous malformations of the brain: natural history in unoperated patients. J Neurol Neurosurg Psychiatry 49(1):1–10PubMedCentralCrossRefPubMed
8.
Zurück zum Zitat da Costa L, Wallace MC, Ter Brugge KG, O’Kelly C, Willinsky RA, Tymianski M (2009) The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 40(1):100–105CrossRefPubMed da Costa L, Wallace MC, Ter Brugge KG, O’Kelly C, Willinsky RA, Tymianski M (2009) The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke 40(1):100–105CrossRefPubMed
9.
Zurück zum Zitat Elhammady MS, Heros RC (2014) Editorial. Management of incidental cerebral AVMs in the post-ARUBA era. J Neurosurg 121(5):1011–1014CrossRefPubMed Elhammady MS, Heros RC (2014) Editorial. Management of incidental cerebral AVMs in the post-ARUBA era. J Neurosurg 121(5):1011–1014CrossRefPubMed
10.
Zurück zum Zitat Graf CJ, Perret GE, Torner JC (1983) Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58(3):331–337CrossRefPubMed Graf CJ, Perret GE, Torner JC (1983) Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58(3):331–337CrossRefPubMed
11.
Zurück zum Zitat Gross BA, Du R (2013) Natural history of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg 118(2):437–443CrossRefPubMed Gross BA, Du R (2013) Natural history of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg 118(2):437–443CrossRefPubMed
12.
Zurück zum Zitat Guo Y, Saunders T, Su H, Kim H, Akkoc D, Saloner DA, Hetts SW, Hess C, Lawton MT, Bollen AW, Pourmohamad T, McCulloch CE, Tihan T, Young WL, University of California, San Francisco Brain Arteriovenous Malformation (UCSF bAVM) Study Project (2012) Silent intralesional microhemorrhage as a risk factor for brain arteriovenous malformation rupture. Stroke 43(5):1240–1246PubMedCentralCrossRefPubMed Guo Y, Saunders T, Su H, Kim H, Akkoc D, Saloner DA, Hetts SW, Hess C, Lawton MT, Bollen AW, Pourmohamad T, McCulloch CE, Tihan T, Young WL, University of California, San Francisco Brain Arteriovenous Malformation (UCSF bAVM) Study Project (2012) Silent intralesional microhemorrhage as a risk factor for brain arteriovenous malformation rupture. Stroke 43(5):1240–1246PubMedCentralCrossRefPubMed
13.
Zurück zum Zitat Halim AX, Johnston SC, Singh V, McCulloch CE, Bennett JP, Achrol AS, Sidney S, Young WL (2004) Longitudinal risk of intracranial hemorrhage in patients with arteriovenous malformation of the brain within a defined population. Stroke 35(7):1697–1702CrossRefPubMed Halim AX, Johnston SC, Singh V, McCulloch CE, Bennett JP, Achrol AS, Sidney S, Young WL (2004) Longitudinal risk of intracranial hemorrhage in patients with arteriovenous malformation of the brain within a defined population. Stroke 35(7):1697–1702CrossRefPubMed
14.
Zurück zum Zitat Hartmann A, Mast H, Mohr JP, Koennecke HC, Osipov A, Pile-Spellman J, Duong DH, Young WL (1998) Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation. Stroke 29(5):931–934CrossRefPubMed Hartmann A, Mast H, Mohr JP, Koennecke HC, Osipov A, Pile-Spellman J, Duong DH, Young WL (1998) Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation. Stroke 29(5):931–934CrossRefPubMed
15.
Zurück zum Zitat Hernesniemi JA, Dashti R, Juvela S, Väärt K, Niemelä M, Laakso A (2008) Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery 63(5):823–829CrossRefPubMed Hernesniemi JA, Dashti R, Juvela S, Väärt K, Niemelä M, Laakso A (2008) Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery 63(5):823–829CrossRefPubMed
16.
Zurück zum Zitat Kelly AG, Holloway RG (2010) Health state preferences and decision-making after malignant middle cerebral artery infarctions. Neurology 75(8):682–687PubMedCentralCrossRefPubMed Kelly AG, Holloway RG (2010) Health state preferences and decision-making after malignant middle cerebral artery infarctions. Neurology 75(8):682–687PubMedCentralCrossRefPubMed
17.
Zurück zum Zitat Kim H, McCulloch CE, Johnston SC, Lawton MT, Sidney S, Young WL (2010) Comparison of 2 approaches for determining the natural history risk of brain arteriovenous malformation rupture. Am J Epidemiol 171(12):1317–1322PubMedCentralCrossRefPubMed Kim H, McCulloch CE, Johnston SC, Lawton MT, Sidney S, Young WL (2010) Comparison of 2 approaches for determining the natural history risk of brain arteriovenous malformation rupture. Am J Epidemiol 171(12):1317–1322PubMedCentralCrossRefPubMed
18.
Zurück zum Zitat Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL, MARS Coinvestigators (2014) Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors. Neurology 83(7):590–597PubMedCentralCrossRefPubMed Kim H, Al-Shahi Salman R, McCulloch CE, Stapf C, Young WL, MARS Coinvestigators (2014) Untreated brain arteriovenous malformation: patient-level meta-analysis of hemorrhage predictors. Neurology 83(7):590–597PubMedCentralCrossRefPubMed
19.
Zurück zum Zitat Korja M, Bervini D, Assaad N, Morgan MK (2014) Role of surgery in the management of brain arteriovenous malformations: prospective cohort study. Stroke 45(12):3549–3555CrossRefPubMed Korja M, Bervini D, Assaad N, Morgan MK (2014) Role of surgery in the management of brain arteriovenous malformations: prospective cohort study. Stroke 45(12):3549–3555CrossRefPubMed
20.
Zurück zum Zitat Laakso A, Dashti R, Seppänen J, Juvela S, Väärt K, Niemelä M, Sankila R, Hernesniemi JA (2008) Long-term excess mortality in 623 patients with brain arteriovenous malformations. Neurosurgery 63(2):244–253CrossRefPubMed Laakso A, Dashti R, Seppänen J, Juvela S, Väärt K, Niemelä M, Sankila R, Hernesniemi JA (2008) Long-term excess mortality in 623 patients with brain arteriovenous malformations. Neurosurgery 63(2):244–253CrossRefPubMed
21.
Zurück zum Zitat Laakso A, Dashti R, Juvela S, Isarakul P, Niemelä M, Hernesniemi J (2011) Risk of hemorrhage in patients with untreated Spetzler–Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients. Neurosurgery 68(2):372–377CrossRefPubMed Laakso A, Dashti R, Juvela S, Isarakul P, Niemelä M, Hernesniemi J (2011) Risk of hemorrhage in patients with untreated Spetzler–Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients. Neurosurgery 68(2):372–377CrossRefPubMed
22.
Zurück zum Zitat Lawton MT, Du R, Tran MN, Achrol AS, McCulloch CE, Johnston SC, Quinnine NJ, Young WL (2005) Effect of presenting hemorrhage on outcome after microsurgical resection of brain arteriovenous malformations. Neurosurgery 56(3):485–493, discussion 485–93CrossRefPubMed Lawton MT, Du R, Tran MN, Achrol AS, McCulloch CE, Johnston SC, Quinnine NJ, Young WL (2005) Effect of presenting hemorrhage on outcome after microsurgical resection of brain arteriovenous malformations. Neurosurgery 56(3):485–493, discussion 485–93CrossRefPubMed
23.
Zurück zum Zitat Meling TR, Proust F, Gruber A, Niemela M, Regli L, Roche PH, Vajkoczy P (2014) On apples, oranges, and ARUBA. Acta Neurochir (Wien) 156(9):1775–1779CrossRef Meling TR, Proust F, Gruber A, Niemela M, Regli L, Roche PH, Vajkoczy P (2014) On apples, oranges, and ARUBA. Acta Neurochir (Wien) 156(9):1775–1779CrossRef
24.
Zurück zum Zitat Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ, international ARUBA investigators (2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 383(9917):614–621PubMedCentralCrossRefPubMed Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ, international ARUBA investigators (2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 383(9917):614–621PubMedCentralCrossRefPubMed
25.
Zurück zum Zitat Ondra SL, Troupp H, George ED, Schwab K (1990) The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 73(3):387–391CrossRefPubMed Ondra SL, Troupp H, George ED, Schwab K (1990) The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 73(3):387–391CrossRefPubMed
26.
Zurück zum Zitat Pierot L, Cognard C, Spelle L (2004) Cerebral arteriovenous malformations: evaluation of the hemorrhagic risk and its morbidity. J Neuroradiol 31(5):369–375CrossRefPubMed Pierot L, Cognard C, Spelle L (2004) Cerebral arteriovenous malformations: evaluation of the hemorrhagic risk and its morbidity. J Neuroradiol 31(5):369–375CrossRefPubMed
27.
Zurück zum Zitat Post PN, Stiggelbout AM, Wakker PP (2001) The utility of health states after stroke: a systematic review of the literature. Stroke 32:1425–1429CrossRefPubMed Post PN, Stiggelbout AM, Wakker PP (2001) The utility of health states after stroke: a systematic review of the literature. Stroke 32:1425–1429CrossRefPubMed
28.
Zurück zum Zitat Rutledge WC, Abla AA, Nelson J, Halbach VV, Kim H, Lawton MT (2014) Treatment and outcomes of ARUBA-eligible patients with unruptured brain arteriovenous malformations at a single institution. Neurosurg Focus 37(3):E8PubMedCentralCrossRefPubMed Rutledge WC, Abla AA, Nelson J, Halbach VV, Kim H, Lawton MT (2014) Treatment and outcomes of ARUBA-eligible patients with unruptured brain arteriovenous malformations at a single institution. Neurosurg Focus 37(3):E8PubMedCentralCrossRefPubMed
29.
Zurück zum Zitat Sahlein DH, Mora P, Becske T, Huang P, Jafar JJ, Connolly ES, Nelson PK (2014) Features predictive of brain arteriovenous malformation hemorrhage: extrapolation to a physiologic model. Stroke 45(7):1964–1970CrossRefPubMed Sahlein DH, Mora P, Becske T, Huang P, Jafar JJ, Connolly ES, Nelson PK (2014) Features predictive of brain arteriovenous malformation hemorrhage: extrapolation to a physiologic model. Stroke 45(7):1964–1970CrossRefPubMed
30.
Zurück zum Zitat Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, Pile-Spellman J, Mohr JP (2006) Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 66(9):1350–1355CrossRefPubMed Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, Pile-Spellman J, Mohr JP (2006) Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology 66(9):1350–1355CrossRefPubMed
31.
Zurück zum Zitat van Beijnum J, Lovelock CE, Cordonnier C, Rothwell PM, Klijn CJ, Al-Shahi Salman R, SIVMS Steering Committee and the Oxford Vascular Study (2009) Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies. Brain 132(Pt 2):537–543PubMed van Beijnum J, Lovelock CE, Cordonnier C, Rothwell PM, Klijn CJ, Al-Shahi Salman R, SIVMS Steering Committee and the Oxford Vascular Study (2009) Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies. Brain 132(Pt 2):537–543PubMed
32.
Zurück zum Zitat van Beijnum J, van der Worp HB, Buis DR, Al-Shahi Salman R, Kappelle LJ, Rinkel GJ, van der Sprenkel JW, Vandertop WP, Algra A, Klijn CJ (2011) Treatment of brain arteriovenous malformations: a systematic review and meta-analysis. JAMA 306(18):2011–2019CrossRefPubMed van Beijnum J, van der Worp HB, Buis DR, Al-Shahi Salman R, Kappelle LJ, Rinkel GJ, van der Sprenkel JW, Vandertop WP, Algra A, Klijn CJ (2011) Treatment of brain arteriovenous malformations: a systematic review and meta-analysis. JAMA 306(18):2011–2019CrossRefPubMed
33.
Zurück zum Zitat Yamada S, Takagi Y, Nozaki K, Kikuta K, Hashimoto N (2007) Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations. J Neurosurg 107(5):965–972CrossRefPubMed Yamada S, Takagi Y, Nozaki K, Kikuta K, Hashimoto N (2007) Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations. J Neurosurg 107(5):965–972CrossRefPubMed
Metadaten
Titel
Microsurgical resection of Spetzler–Martin grades 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity and loss of quality-adjusted life-years (QALY) than conservative management—results of a single group series
verfasst von
Hans-Jakob Steiger
Igor Fischer
Benjamin Rohn
Bernd Turowski
Nima Etminan
Daniel Hänggi
Publikationsdatum
01.08.2015
Verlag
Springer Vienna
Erschienen in
Acta Neurochirurgica / Ausgabe 8/2015
Print ISSN: 0001-6268
Elektronische ISSN: 0942-0940
DOI
https://doi.org/10.1007/s00701-015-2474-9

Weitere Artikel der Ausgabe 8/2015

Acta Neurochirurgica 8/2015 Zur Ausgabe

Letter to the editor - Neurosurgical Anatomy

Anatomy of lumbosacral spinal nerve roots

Leitlinien kompakt für die Neurologie

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Neurologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.