Clinical study
Prospective study of neuropsychological and psychosocial outcome following surgical excision of intracerebral arteriovenous malformations

https://doi.org/10.1016/S0967-5868(02)00217-5Get rights and content

Abstract

In this prospective study the neuropsychological and psychosocial function of 64 patients undergoing surgical resection of cerebral arteriovenous malformations was examined prior to surgery (T1), one month post-surgery (T2) and one year post-surgery (T3). A mild but widespread cognitive decline was observed pre-operatively. There was a trend toward decreased neuropsychological function at T2. All neuropsychological tests showed a trend toward improvement at T3 compared with both pre-operative (generally not statistically significant) and early post-operative values (generally significant). Patients were assessed for change between testing times. At T2 patients were more likely to have deteriorated than improved, whereas at T3 the group which had altered from baseline were more likely to have improved than deteriorated. Deterioration in some verbal/language tasks was more common for left sided AVMs. Outcome did not differ significantly for patients presenting with haemorrhage. Psychosocial function was unchanged at late follow-up for the majority of patients.

Introduction

Patients harboring intracranial arteriovenous malformations (AVMs) present with a diverse range of clinical features which include haemorrhage, seizures, headaches, focal neurological deficits, and ‘mental changes’.[1], [2], [3], [4], [5] These ‘mental changes’ have been well documented in a number of case reports,[6], [7], [8], [9], [10] but overt cognitive impairment appears to account for only a small proportion of overall presentations.4

Decisions regarding treatment of these lesions are necessarily complex, and involve balancing the risks and benefits of various treatment options such as surgical excision, embolization, radiosurgery, and conservative management. Whilst sufficient data is available concerning mortality and neurological morbidity,[11], [12], [13] cognitive and psychosocial outcome have been reported less frequently.[14], [15] Knowledge of the likely cognitive and psychosocial outcome following surgery could assist clinicians in their decision making.

In this prospective study a large, relatively unselected group of patients underwent comprehensive neuropsychological and psychosocial evaluation both prior to and following surgery in order to determine the effects of AVM excision on cognitive functioning.

Section snippets

Patients

Between July 1992 and March 1996 110 patients underwent radical surgical excision of supratentorial AVMs of the brain by the neurosurgeon (MKM) and were considered for eligibility by the following criteria:

  • 1.

    aged between 16 and 75 years.

  • 2.

    fluent English speakers.

  • 3.

    no history of previous neurological or psychological disease unrelated to the AVM.

  • 4.

    cerebral AVM was confirmed angiographically prior to surgery.

  • 5.

    sufficiently alert and attentive to undertake neuropsychological testing.

  • 6.

    initial surgery

Study population

Demographic data for the 64 eligible patients is provided in Table 1, along with the equivalent information for the 51 patients who were included in statistical analysis, and the eleven patients excluded from analysis because of incomplete data (excluding the 2 patients who died). Patients with data on all 3 occasions did not differ significantly with those who were excluded. As can be seen in Table 1, the patient sample who underwent statistical analysis in this study is representative of the

Preoperative cognitive and psychosocial status

Preoperatively, our patients showed significant reductions in general cognitive abilities compared with expected levels. Although the overall differences were of small magnitude, they were highly significant for two of the three indices. These results suggest that some degree of cognitive impairment is common in patients harboring AVMs. This is consistent with other contemporary studies in which neuropsychological evaluation has been undertaken.[14], [24], [25], [26], [27] The current study

Conclusions

We conclude that AVM surgery has a relatively benign effect on cognitive and psychosocial functioning in the vast majority of patients. At one year most patients perform similarly to pre-operative levels on most cognitive tasks. Of the small group of patients showing a change in cognitive function at 1 year, improvement is slightly more common than deterioration. As expected, deterioration in some verbal and language tasks is more common with surgery for left sided AVMs. There is no increased

References (49)

  • F Wenz et al.

    Assessment of neuropsychological changes in patients with arteriovenous malformation (AVM) after radiosurgery

    Int. J. Radiat. Oncol. Biol. Phys.

    (1998)
  • H Mast et al.

    ‘Steal’ is an unestablished mechanism for the clinical presentation of cerebral arteriovenous malformations

    Stroke

    (1995)
  • H Olivecrona et al.

    Arteriovenous aneurysms of the brain

    Arch. Neurol. Psychiatry

    (1948)
  • J.H Paterson et al.

    A clinical survey of intracranial angiomas with special reference to their mode of progression and surgical treatment: A report of 110 cases

    Brain

    (1956)
  • G Perret et al.

    Report on the cooperative study of intracranial aneurysms and subarachnoid haemorrhage. Section VI. Arteriovenous malformations and fistulae reported to the cooperative study

    J. Neurosurg.

    (1966)
  • R Wyburn-Mason

    Arteriovenous aneurysm of mid-brain and retina, facial naevi and mental changes

    Brain

    (1943)
  • R.T Wertz et al.

    Right hemisphere language dominance in a case of left hemisphere arteriovenous malformation

    J. Speech Hear Disord.

    (1977)
  • J.J v Overbeeke et al.

    Higher cortical disorders: An unusual presentation of an arteriovenous malformation

    Neurosurgery

    (1987)
  • S.P Koffler et al.

    Replacement of dominant temporal lobe by arteriovenous malformation with minimal neuropsychological impairment: Report of a case

    Neuropsychology

    (1990)
  • P.L Carter et al.

    Psychological improvement following arteriovenous malformation excision

    J. Neurosurg.

    (1975)
  • F Conley et al.

    Deficits of higher cortical functioning in two patients with posterior parietal arteriovenous malformations: Use of a standardized Luria–Nebraska neuropsychological battery for pre- and postoperative assessment

    Neurosurgery

    (1980)
  • M.K Morgan et al.

    Delayed neurological deterioration following resection of arteriovenous malformations of the brain

    J Neurosurg

    (1999)
  • M.K Morgan et al.

    Complications of surgery for arteriovenous malformations of the brain

    J Neurosurg

    (1993)
  • R.C Heros et al.

    Surgical excision of cerebral arteriovenous malformations: Late results

    Neurosurgery

    (1990)
  • K.E Stabell et al.

    Prospective neuropsychological investigation of patients with supratentorial arteriovenous malformations

    Acta Neurochir (Wien)

    (1994)
  • D.M Mahalick et al.

    Preoperative versus postoperative neuropsychological sequelae of arteriovenous malformations

    Neurosurgery

    (1993)
  • Nelson

    The National Adult Reading Test: Test Manual

    (1982)
  • D Willshire et al.

    Estimating the WAIS-R IQ from the National Adult Reading Test: A cross-validation

    J. Clin. Exper. Neuropsych.

    (1991)
  • S Holm

    A simple sequentially rejective multiple test procedure

    Scand. J. Stat.

    (1979)
  • B Hermann et al.

    Empirical techniques for determining the reliability, magnitude, and pattern of neuropsychological change after epilepsy surgery

    Epilepsia

    (1996)
  • S Sawrie et al.

    Empirical methods for assessing meaningful neuropsychological change following epilepsy surgery

    J. Int. Neuropsych. Soc.

    (1996)
  • G Chelune et al.

    Individual change after epilepsy surgery: Practice effects and base-rate information

    Neuropsychology

    (1993)
  • N Jacobson et al.

    Clinical significance: A statistical approach to defining meaningful change in psychotherapy research

    J. Consult. Clin. Psychol.

    (1991)
  • W Stanish et al.

    The use of CATMOD for repeated measurement analysis for categorical data

  • Cited by (17)

    • Vascular intracranial malformations and dementia: An under-estimated cause and clinical correlation. Clinical note

      2022, Cerebral Circulation - Cognition and Behavior
      Citation Excerpt :

      Pathological data have shown that approximately 12% of AVM's become symptomatic and the others are captured either inadvertently or at autopsy [24]. In most cases reported in the literature, there is a longstanding assumption that AVMs cause focal cognitive deficits by a ‘‘steal phenomenon’’; that is, by directing increased blood flow toward the AVM and away from other regions of the brain [25]. The cerebral steal mechanism is thought to decrease normal perfusion and cause hypoperfusion in adjacent and distant brain areas.

    • Neuropsychological outcomes of stereotactic radiotherapy for cerebral arteriovenous malformations

      2014, Journal of Clinical Neuroscience
      Citation Excerpt :

      The findings of studies that have investigated cognition in patients with small, large and eloquently located AVMs prior to treatment are somewhat mixed. Some studies have found normal cognition in AVM patients [22,23], while other studies have demonstrated cognitive impairment in this patient population [24–26]. These mixed findings may be due to the heterogeneity of the patients studied (for example, AVMs of differing sizes and locations, differing degrees of steal).

    • Cognitive dysfunction in AVM of the brain

      2020, Arteriovenous Malformations of the Brain
    • Neuropsychological Effects of Brain Arteriovenous Malformations

      2020, Neurovascular Neuropsychology: Second Edition
    • Clinical value of functional MRI in the diagnosis of cognitive disorders in patients with arteriovenous malformations

      2020, BIODEVICES 2020 - 13th International Conference on Biomedical Electronics and Devices, Proceedings; Part of 13th International Joint Conference on Biomedical Engineering Systems and Technologies, BIOSTEC 2020
    View all citing articles on Scopus
    View full text