Clinical studyProspective study of neuropsychological and psychosocial outcome following surgical excision of intracerebral arteriovenous malformations
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)
- et al.
Assessment of neuropsychological changes in patients with arteriovenous malformation (AVM) after radiosurgery
Int. J. Radiat. Oncol. Biol. Phys.
(1998) - et al.
‘Steal’ is an unestablished mechanism for the clinical presentation of cerebral arteriovenous malformations
Stroke
(1995) - et al.
Arteriovenous aneurysms of the brain
Arch. Neurol. Psychiatry
(1948) - 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) - 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) Arteriovenous aneurysm of mid-brain and retina, facial naevi and mental changes
Brain
(1943)- et al.
Right hemisphere language dominance in a case of left hemisphere arteriovenous malformation
J. Speech Hear Disord.
(1977) - et al.
Higher cortical disorders: An unusual presentation of an arteriovenous malformation
Neurosurgery
(1987) - et al.
Replacement of dominant temporal lobe by arteriovenous malformation with minimal neuropsychological impairment: Report of a case
Neuropsychology
(1990) - et al.
Psychological improvement following arteriovenous malformation excision
J. Neurosurg.
(1975)
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
Delayed neurological deterioration following resection of arteriovenous malformations of the brain
J Neurosurg
Complications of surgery for arteriovenous malformations of the brain
J Neurosurg
Surgical excision of cerebral arteriovenous malformations: Late results
Neurosurgery
Prospective neuropsychological investigation of patients with supratentorial arteriovenous malformations
Acta Neurochir (Wien)
Preoperative versus postoperative neuropsychological sequelae of arteriovenous malformations
Neurosurgery
The National Adult Reading Test: Test Manual
Estimating the WAIS-R IQ from the National Adult Reading Test: A cross-validation
J. Clin. Exper. Neuropsych.
A simple sequentially rejective multiple test procedure
Scand. J. Stat.
Empirical techniques for determining the reliability, magnitude, and pattern of neuropsychological change after epilepsy surgery
Epilepsia
Empirical methods for assessing meaningful neuropsychological change following epilepsy surgery
J. Int. Neuropsych. Soc.
Individual change after epilepsy surgery: Practice effects and base-rate information
Neuropsychology
Clinical significance: A statistical approach to defining meaningful change in psychotherapy research
J. Consult. Clin. Psychol.
The use of CATMOD for repeated measurement analysis for categorical data
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Vascular intracranial malformations and dementia: An under-estimated cause and clinical correlation. Clinical note
2022, Cerebral Circulation - Cognition and BehaviorCitation 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 NeuroscienceCitation 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 BrainNeuropsychological Effects of Brain Arteriovenous Malformations
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