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Raki C, Xenos C, Lai LT. Is Supplemented Spetzler-Martin grading Superior? A comparative study in AVM microsurgery risk stratification. J Clin Neurosci 2025; 137:111311. [PMID: 40349589 DOI: 10.1016/j.jocn.2025.111311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2025] [Revised: 04/26/2025] [Accepted: 05/05/2025] [Indexed: 05/14/2025]
Abstract
The Spetzler-Martin (SM) grading system remains the most widely adopted classification for brain arteriovenous malformations (AVMs). The Supplemented Spetzler-Martin (Supp-SM) system was developed to improve surgical risk stratification by incorporating patient age, rupture status, and nidus diffuseness. However, data comparing its predictive validity remain limited. This study investigates the predictive relevance of SM and Supp-SM grading for postoperative neurological morbidity following AVM microsurgery at a single tertiary cerebrovascular centre. A retrospective review identified 96 patients who underwent AVM microsurgical resection, with or without preoperative embolisation, between 2015 and 2024. Postoperative morbidity was defined as worsened modified Rankin Scale (mRS) score at 90 days. Predictive accuracy was analysed using ROC curves, correlation with postoperative mRS scores, and Supp-SM risk threshold. Postoperative morbidity occurred in 9 patients (9.4 %). ROC analysis revealed no significant difference between SM (AUROC 0.717; 95 % CI 0.55-0.88) and Supp-SM (AUROC 0.667; 95 % CI 0.46-0.88) scores, p = 0.3899. However, Supp-SM scores demonstrated a stronger correlation with postoperative mRS changes (Spearman's ρ = 0.269, p = 0.008) than SM grades (Spearman's ρ = 0.144, p = 0.161). Patients with Supp-SM grades < 6 had a 3.2 % morbidity risk, compared with a 20.6 % risk for scores ≥ 6 (p = 0.009). A Supp-SM threshold of 6 demonstrated the highest discriminative accuracy in differentiating high- and low-risk surgical candidates. While no significant predictive difference was found between SM and Supp-SM grading, a Supp-SM score of ≥ 6 was associated with substantially higher morbidity. These findings support the adjunctive use of Supp-SM grading for surgical risk assessment in AVM patients.
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Affiliation(s)
- Cyrus Raki
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia; Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Chris Xenos
- Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Level 5, Block D, 246 Clayton Road, Clayton, Victoria 3168, Australia; Department of Surgery, Monash Medical Centre, Level 5, Block E, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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Orscelik A, Musmar B, Matsukawa H, Ismail M, Elawady SS, Assad S, Cunningham C, Sowlat MM, Spiotta AM. Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2025; 96:18-28. [PMID: 38912816 DOI: 10.1227/neu.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). METHOD Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. RESULTS MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). CONCLUSION This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.
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Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Mustafa Ismail
- College of Medicine, University of Baghdad, Baghdad , Iraq
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Salman Assad
- Department of Neurology, University of Nebraska Medical Center, Omaha , Nebraska , USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
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Yang T, Liu Y, Yuan B, Han Y, Xiang Y, Sun J, Guo W, Chen M, Wang H. Three-Pillar Expansive Craniotomy in Children with Acute Ruptured Supratentorial Brain Arteriovenous Malformations. World Neurosurg 2024; 189:e347-e354. [PMID: 38878889 DOI: 10.1016/j.wneu.2024.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 06/09/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Acute rupture and hemorrhage of pediatric brain arteriovenous malformations (AVMs) may lead to cerebral herniation or intractable intracranial hypertension, necessitating emerging surgical interventions to alleviate intracranial pressure. However, there is still controversy regarding the timing of treatment for ruptured AVMs. This study aimed to assess the feasibility of utilizing three-pillar expansive craniotomy (3PEC) at different times during the treatment of pediatric ruptured supratentorial AVMs. METHODS A retrospective analysis was conducted on all consecutive cases of acute rupture in supratentorial AVM children who underwent 3PEC at a single institution from 2020 to 2022. General information, clinical characteristics, radiological data, and prognosis were reviewed and analyzed. RESULTS Thirteen children were included in the analysis. The intracranial pressure of all patients decreased to below 15 mmHg within 10 days. The expansion volume of the cranial cavity of the patients increased by 18.3 cm3 (95% confidence interval, 10.2-26.3; P < 0.001) compared to the hematoma volume. None of the patients required decompressive craniectomy due to intractable intracranial hypertension caused by cerebral swelling. The median waiting period for patients with delayed AVMs treatment was 8 days, during which no rebleeding occurred. CONCLUSIONS Emergency intervention with 3PEC in children experiencing acutely ruptured supratentorial AVMs appears to be feasible. For children requiring delayed management of the AVMs, 3PEC may diminish the risk of rebleeding during the waiting period and shorten the waiting period.
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Affiliation(s)
- Tianquan Yang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yuchen Liu
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Bin Yuan
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yong Han
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yongjun Xiang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jingxuan Sun
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wanliang Guo
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Min Chen
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hangzhou Wang
- Department of Neurosurgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
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Garcia JH, Carrete L, Rutledge WC, Raygor KP, Winkler EA, Pereira MP, Nelson J, Kim H, Cooke DL, Hetts SW, Lawton MT, Abla AA. Factors Associated with Unfavorable Clinical Presentations in Patients with Ruptured BrainArteriovenous Malformations. World Neurosurg 2023; 178:e72-e78. [PMID: 37422187 DOI: 10.1016/j.wneu.2023.06.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Rupture of brain arteriovenous malformations (bAVMs) carries potentially devastating consequences. For patients presenting with ruptured bAVMs, several clinical grading systems have been shown to predict long-term patient morbidity and may be taken into consideration when making clinical decisions. Unfortunately, use of these scoring systems is typically limited to their prognostic value and offer little to patients in therapeutic benefit. Tools are needed not only to predict prognosis for patients experiencing ruptured bAVMs but to gain insight into what characteristics predispose patients to poor long-term outcomes before they rupture. Our objective was to find clinical, morphologic, and demographic variables that correlate with unfavorable clinical grades on presentation in patients with ruptured bAVMs. METHODS We retrospectively reviewed a cohort of patients with ruptured bAVMs. Linear regression models were used to test whether Glasgow Coma Scale (GCS) and Hunt-Hess scores on presentation(outcomes) were associated with patient and arteriovenous malformation (AVM) characteristics (predictors) individually. RESULTS GCS and Hunt-Hess were assessed following bAVM rupture for 121 brain cases. The median age at rupture was 28.5 years, and 62 (51%) were female. Smoking history was associated with worse GCS; current and past smokers had GCS scores 1.33 points lower on average than nonsmokers (95% confidence interval [CI] -2.59 to -0.07, P = 0.039) and had worse Hunt-Hess scores (0.42, 95% CI 0.07-0.77, P = 0.019). Associated aneurysms were associated with worse GCS (-1.60, 95% CI -3.16 to -0.05, P = 0.043) and trended towards worse Hunt-Hess scores (0.42 points, 95% CI -0.01 to 0.86, P = 0.057). CONCLUSIONS Patient smoking status and presence of an AVM associated aneurysm were shown to have modest correlations with unfavorable clinical grades (Hunt-Hess, GCS) on presentation, with unfavorable clinical grades being associated with long-term patient prognosis following bAVM rupture. Further investigation using AVM-specific grading scales and external data are needed to determine the utility of these and other variables in clinical practice for patients with bAVM.
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Affiliation(s)
- Joseph H Garcia
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Carrete
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matheus Prado Pereira
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA.
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Bintang AK, Bahar A, Akbar M, Soraya GV, Gunawan A, Hammado N, Rachman ME, Ulhaq ZS. Delayed versus immediate intervention of ruptured brain arteriovenous malformations: A case report. World J Clin Cases 2023; 11:1992-2001. [PMID: 36998967 PMCID: PMC10044944 DOI: 10.12998/wjcc.v11.i9.1992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) remains one of the most prevalent causes of intracranial hemorrhage and stroke-like syndromes in the young adult population. Although it has been agreed upon that definitive treatment using either single or multi-modal approach is warranted for successful bAVM management, much debate still revolves regarding the optimal timing of definitive treatment.
CASE SUMMARY In this report, we present a case of delayed, definitive endovascular treatment for ruptured bAVM in a 21-year-old female, 3 mo post-ictus. The bAVM, with a left pericallosal feeding artery and cortical draining veins, was successfully obliterated through embolization using the Onyx 18. On follow-up the patient has recommenced her daily activities and experiences only mild occasional headaches with mild motor deficits. The report leads to our review on an important issue regarding the optimal timing of ruptured bAVM definitive management and bring forward the current evidence available on delayed vs immediate definitive bAVM intervention. We also highlight current issues that need to be addressed for clearer guidelines on definitive therapy initiation.
CONCLUSION Current treatment paradigms of ruptured bAVM remains elusive, with substantial heterogeneity in the current literature. A consensus on the definition of “acute” vs “delayed”, management goal, follow-up length and outcome parameters are required to support formation of a clear paradigm.
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Affiliation(s)
| | - Ashari Bahar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Muhammad Akbar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Gita Vita Soraya
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Department of Biochemistry, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia
| | - Anthony Gunawan
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Nurussyariah Hammado
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Health and Sport Science, State University of Makassar, Makassar 90222, Indonesia
| | - Mochammad Erwin Rachman
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Medicine, Muslim University of Indonesia, Makassar 90231, Indonesia
| | - Zulvikar Syambani Ulhaq
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency Republic of Indonesia, Cibinong 16911, Indonesia
- Laboratory of Developmental Disorders and Toxicology, Kyushu University, Fukuoka 8190395, Japan
- Department of Biomedical Science, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University, Malang 65144, Indonesia
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Rodriguez-Calienes A, Vivanco-Suarez J, Borjas-Calderón NF, Chavez-Ecos FA, Fernández DEM, Malaga M, Basilio Flores JE, Ortega-Gutierrez S, Saal-Zapata G. Curative embolization of ruptured pediatric cerebral arteriovenous malformations. Clin Neurol Neurosurg 2023; 227:107663. [PMID: 36868088 DOI: 10.1016/j.clineuro.2023.107663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Embolization with the intention to cure has not been well studied in ruptured arteriovenous malformations (AVMs). Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization of ruptured pediatric AVMs and assess predictors of obliteration and complications. METHODS A retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization of ruptured AVMs was conducted in two institutions between 2010 and 2022. The efficacy (complete angiographic obliteration after the last embolization session), recurrence (radiological recurrence of the lesion after confirmed obliteration in follow-up imaging), and safety (procedure-related complications and mortality) of the procedure were evaluated. RESULTS Sixty-eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. Median follow-up time was 18 months after embolization (ranged from 2 to 47 months). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. Recurrence of a totally embolized lesion occurred in 9 patients (13%). Thirteen complications (11.9% of procedures) were observed, and no deaths were reported. A nidus size > 2 cm was the only independent predictor of complete obliteration (OR = 0.16; 95% CI 0.03 - 0.77; p = 0.030). CONCLUSION Embolization of pediatric ruptured AVMs with curative intent can achieve acceptable obliteration rates. However, recurrence after complete obliteration and procedure-related complications of curative embolization of these lesions cannot be ignored. Ruptured AVMs ≤ 2 cm are adequate to achieve complete obliteration with curative endovascular management.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nagheli Fernanda Borjas-Calderón
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru
| | - Fabian A Chavez-Ecos
- Sociedad Científica de Estudiantes de Medicina de Ica, Universidad Nacional San Luis Gonzaga, Ica, Peru; Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | | | - Marco Malaga
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service. Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru.
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Ismail M, Al-Ageely TA, Talib SH, Hadi RT, Al-Taie RH, Aktham AA, Alrawi MA, Salih HR, Al-Jehani H, Hoz SS. Atypical slow-flow paramedian AVM with venous varix. Surg Neurol Int 2022; 13:519. [DOI: 10.25259/sni_920_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Cerebral arteriovenous malformations (CAVMs) are either clinically silent or symptomatic. The most common presentation in more than half of all CAVMs presenting patients is hemorrhage which is accompanied by long-standing neurological morbidity and mortality. This report presents a case of an atypical large, slow-flow paramedian AVM with a dilated venous varix managed with surgery. The impact of the intraoperative findings on the diagnosis and the operative technique will be discussed.
Case Description:
In otherwise, healthy 26-year-old male complained of repeated episodes of generalized seizures and loss of consciousness. Brain magnetic resonance imaging (MRI) revealed a right parietal paramedian arteriovenous malformation (AVM) with signs of an old hemorrhagic cavity beneath it. Digital subtraction angiography demonstrated a slow-filling AVM with dilated venous varix drains into the superior sagittal sinus. However, the exact point of drainage cannot be appreciated. The filling of the AVM occurred precisely with the beginning of the venous phase. Intraoperatively, we noticed a whitish spherical mass, thick hemosiderin tissue, and a large cavity below the nidus; then, a complication-free complete microsurgical resection of this high-grade AVM was performed. Postoperatively, the patient suffered two attacks of seizures in the first few hours after the surgery, for which he received antiepileptics. MRI was clear during follow-up, and the patient was seizure-free and neurologically intact.
Conclusion:
Parietal convexity AVMs are challenging lesions to tackle. However, the chronicity and the slow-filling of the AVM, in this case, can render the surgical pathway more direct and accessible.
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Affiliation(s)
- Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Teeba A. Al-Ageely
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Sura H. Talib
- Department of Neurosurgery, University of Al-Mustansiriyah, College of Medicine, Baghdad, Iraq,
| | - Rania Thamir Hadi
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Rania H. Al-Taie
- Department of Neurosurgery, University of Al-Mustansiriyah, College of Medicine, Baghdad, Iraq,
| | - Awfa A. Aktham
- Department of Neurosurgery, Tokyo General Hospital, Nakano, Japan,
| | - Mohammed A. Alrawi
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq,
| | - Hayder R. Salih
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq,
| | - Hosam Al-Jehani
- Department of Neurosurgery, Imam Abdulrahman Alfaisal University, Dammam, Saudi Arabia,
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States
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Tsentsiper LM, Dryagina NV, Terekhov IS, Aybazova MI, Rumyantseva MV, Petrov AE, Petrova AO, Kondratyev AN. Inflammatory Response in Patients with Spontaneous Intracranial Hemorrhages. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-5-71-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mortality and disability rates in spontaneous intracranial hemorrhages remain high despite medical advances. In recent decades, much attention has been paid to neuroinflammation as a typical response to brain damage. Inflammation plays an important role in the acute and chronic phases of the disease. The relationship between plasma and cerebrospinal fluid cytokines, as well as the factors affecting their ratios, is currently not completely clear.The objective was to study the inflammatory response to spontaneous intracranial hemorrhage.Subjects and Methods. 59 patients aged 18 to 72 years (48 ± 6) were enrolled in the study. Patients were admitted to the intensive care unit after an episode of spontaneous intracranial hemorrhage. The levels of interleukins in blood plasma were studied: 6, 8, 10, TNF-α, C-reactive protein,blood leukocytes, and procalcitonin (by a semi-quantitative method). In the cerebrospinal fluid, the following parameters were evaluated: cytosis, protein, glucose, lactate, cytokines (6, 8, 10, TNF-α). Blood samples were collected on days 1, 2, 3, 5, 7, 9, 14, 21, 28, 35, and 45.Results. Systemic inflammatory response developed in all patients from the first day of acute brain injury. The most significant response was formed by glial brain cells which was confirmed by high levels of cytokines in the cerebrospinal fluid, hundreds and thousands of times higher than blood levels of cytokines.Conclusion. Levels of pro-inflammatory cytokines are predictors of an unfavorable outcome.
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Affiliation(s)
- L. M. Tsentsiper
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - N. V. Dryagina
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - I. S. Terekhov
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - M. I. Aybazova
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - M. V. Rumyantseva
- North-Western District Scientific and Clinical Center Named after L. G. Sokolov
| | - A. E. Petrov
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | | | - A. N. Kondratyev
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
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9
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The Potential Value of 320-Row Computed Tomography Angiography in Digital Subtraction Angiography-Negative Spontaneous Subarachnoid Hemorrhage Patients. J Comput Assist Tomogr 2022; 46:244-250. [PMID: 35081605 PMCID: PMC8929304 DOI: 10.1097/rct.0000000000001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objective This study aimed to investigate the clinical value of multiphase and multiparametric 320-row computed tomography (CT) in the long-term follow-up of spontaneous subarachnoid hemorrhage (SAH) with initially negative CT angiography (CTA) and digital subtraction angiography (DSA) results. Methods We retrospectively analyzed the clinical data of 35 patients with nontraumatic angiographically negative SAH results from February 2012 to December 2015. Regular follow-up was performed with 320-row CTA, CT venography, and CT perfusion. Results All patients received 320-row CT follow-up for 0.5 to 4 years. The diagnostic yield of the follow-up examinations was 4 of 35 (11.4%), 3 of 31 (9.7%), and 1 of 28 (3.6%) for the first, second, and third time points, respectively. Two patients were admitted to the hospital because of recurrent subarachnoid hemorrhage during the follow-up period and diagnosed with ruptured aneurysms. Conclusions Patients with SAH with negative findings in the first DSA examination require to follow up. Follow-up using 320-row CTA, CT venography, and CT perfusion allows for a noninvasive diagnostic test for cerebrovascular diseases with higher compliance and fewer complications when compared with follow-up using DSA.
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10
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Decompressive hemicraniectomies as damage control for ruptured intracranial arteriovenous malformations: A case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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11
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Acute spontaneous subdural hematoma secondary to ruptured arteriovenous malformation: A rare entity. Ann Med Surg (Lond) 2021; 68:102613. [PMID: 34381601 PMCID: PMC8340043 DOI: 10.1016/j.amsu.2021.102613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Acute spontaneous subdural hematoma (ASSDH) due to ruptured arteriovenous malformation (AVM) is exceptional. There were only four reported cases. In this paper, we present a successful multimodality treatment of the ASSDH secondary to ruptured AVM. Case presentation A 21-year-old healthy man with no history of trauma presented to our hospital with complaints of severe headache for 12 hours before admission. On examination, he was alert and oriented. He had no intracranial hypertension, meningismus, and neurological deficits. Computed tomography illustrated a right acute subdural hematoma 8mm in thickness with a 5mm midline shift and a right frontal intraparenchymal hemorrhage 40 × 25mm in size. Digital subtraction angiography showed a 2 × 3 cm right frontal AVM, Spetzler-Martin grade I. The feeding arteries were cortical branches of the right anterior cerebral artery, and drain veins were cortical veins. He received emergency preoperative embolization followed by hematoma evacuation and total excision of the malformation. His headache was relieved and disappeared after a week. No postoperative neurological deficits were reported. Clinical discussion Elective surgical resection of AVM after 4–6 weeks was preferred in patients with no risk factors of rebleeding. Emergent surgery was only indicated for significant mass effect or acute hydrocephalus. Preoperative embolization is helpful for the presence of intra-nidal or peri-nidal aneurysm, AVM with high grades, reducing intraoperative blood loss and occlusion of deep vessels. Conclusion ASSDH due to ruptured AVM is rare and easy to omit in clinical settings. Preoperative embolization and surgical excision are effective treatments.
Acute spontaneous SDH due to ruptured AVM is quite rare and easy to omit in clinical settings. Prompt CTA or MRA should be considered initial screening tools when available to rule out a ruptured AVM. Preoperative embolization and surgical excision are the mainstays of treatment of ruptured AVMs.
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Stricker S, Boulouis G, Benichi S, Bourgeois M, Gariel F, Garzelli L, Hak JF, Alias Q, Kerleroux B, Beccaria K, Chivet A, de Saint Denis T, James S, Paternoster G, Zerah M, Kossorotoff M, Boddaert N, Brunelle F, Meyer P, Puget S, Naggara O, Blauwblomme T. Acute surgical management of children with ruptured brain arteriovenous malformation. J Neurosurg Pediatr 2021; 27:437-445. [PMID: 33482644 DOI: 10.3171/2020.8.peds20479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM. METHODS This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury. RESULTS A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently. CONCLUSIONS HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.
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Affiliation(s)
| | - Grégoire Boulouis
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Florent Gariel
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Lorenzo Garzelli
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | - Basile Kerleroux
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | | | | | | | | | | | | | | | - Nathalie Boddaert
- 1APHP, Necker Hospital
- 2Université de Paris
- 4INSERM U1163, Imagine Institute, Paris, France
| | | | | | | | - Olivier Naggara
- 1APHP, Necker Hospital
- 2Université de Paris
- 3INSERM U1266, Department of Neuroradiology, Sainte-Anne Hospital, GHU Paris Psychiatry and Neurosciences; and
| | - Thomas Blauwblomme
- 1APHP, Necker Hospital
- 2Université de Paris
- 4INSERM U1163, Imagine Institute, Paris, France
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Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study. CHILDREN-BASEL 2021; 8:children8030215. [PMID: 33799749 PMCID: PMC7998913 DOI: 10.3390/children8030215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
Abstract
Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.
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Stagnant venous outflow in ruptured arteriovenous malformations revealed by delayed quantitative digital subtraction angiography. Eur J Radiol 2020; 134:109455. [PMID: 33296802 DOI: 10.1016/j.ejrad.2020.109455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To investigate the reproducibility of quantitative digital subtraction angiography (QDSA) measurements and their associations with brain arteriovenous malformation (BAVM) hemorrhage. METHODS From 2011-2019, 37 patients with BAVMs who had undergone both diagnostic and stereotactic DSA were divided into hemorrhagic and nonhemorrhagic groups. QDSA analysis was performed on the 2 DSA exams. The inter-exam reliabilities of QDSA measurements across the diagnostic and stereotactic DSA were tested using intraclass correlation coefficients (ICCs). Demographics, BAVM characteristics, and QDSA results for the hemorrhagic and nonhemorrhagic groups were compared. RESULTS Fifteen of 37 (40.5 %) patients presented with hemorrhage were associated with smaller BAVM volume and the presence of intranidal aneurysm and exclusive deep venous drainage. The median interval between the diagnostic and stereotactic DSA was 49 days and did not differ between the groups. In both groups, the inter-exam QDSA measurements were more reliable for drainage veins and transnidal time (ICCs ranged from 0.38-0.93) than for feeding arteries (ICCs ranged from 0.01-0.74). Among the venous parameters, the hemorrhagic group had lower peak density, area under the curve, inflow gradient, and outflow gradient on both DSA exams and larger full width at half maximum and stasis index on the stereotactic DSA exam than the nonhemorrhagic group. CONCLUSIONS In BAVMs, the QDSA measurements for veins are more reliable than those for arteries. QDSA analysis reflecting stagnant venous drainage is associated with BAVM hemorrhage, but may be confounded by the acute hemodynamic change after hemorrhage.
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Di Bartolomeo A, Scafa AK, Giugliano M, Dugoni DE, Ruggeri AG, Delfini R. Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases. J Neurosci Rural Pract 2020; 12:4-11. [PMID: 33551615 PMCID: PMC7857959 DOI: 10.1055/s-0040-1716792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.
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Affiliation(s)
- Alessandro Di Bartolomeo
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Anthony Kevin Scafa
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Marco Giugliano
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Demo Eugenio Dugoni
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Andrea Gennaro Ruggeri
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto Delfini
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
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Unnithan AKA. Overview of the current concepts in the management of arteriovenous malformations of the brain. Postgrad Med J 2020; 96:212-220. [DOI: 10.1136/postgradmedj-2019-137202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/12/2019] [Accepted: 01/11/2020] [Indexed: 12/12/2022]
Abstract
BackgroundThere is a lack of consensus in the management of arteriovenous malformations (AVMs) of the brain since ARUBA (A Randomised trial of Unruptured Brain Arteriovenous malformations) trial showed that medical management is superior to interventional therapy in patients with unruptured brain AVMs. The treatment of brain AVM is associated with significant morbidity.Objectives and methodsA review was done to determine the behaviour of brain AVMs and analyse the risks and benefits of the available treatment options. A search was done in the literature for studies on brain AVMs. Descriptive analysis was also done.ResultsThe angiogenic factors such as vascular endothelial growth factor and inflammatory cytokines are involved in the growth of AVMs. Proteinases such as matrix metalloproteinase-9 contribute to the weakening and rupture of the nidus. The risk factors for haemorrhage are prior haemorrhage, deep and infratentorial AVM location, exclusive deep venous drainage and associated aneurysms. The advancements in operating microscope and surgical techniques have facilitated microsurgery. Stereotactic radiosurgery causes progressive vessel obliteration over 2–3 years. Endovascular embolisation can be done prior to microsurgery or radiosurgery and for palliation.ConclusionsSpetzler-Martin grades I and II have low surgical risks. The AVMs located in the cerebellum, subarachnoid cisterns and pial surfaces of the brainstem can be treated surgically. Radiosurgery is preferable for deep-seated AVMs. A combination of microsurgery, embolisation and radiosurgery is recommended for deep-seated and Spetzler-Martin grade III AVMs. Observation is recommended for grades IV and V.
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Targeted endovascular treatment for ruptured brain arteriovenous malformations. Neurosurg Rev 2019; 43:1509-1518. [DOI: 10.1007/s10143-019-01205-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022]
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Schuss P, Hadjiathanasiou A, Ilic I, Brandecker S, Güresir Á, Vatter H, Güresir E. Risk of Rebleeding in Patients Suffering From Ruptured Brain Arteriovenous Malformations Undergoing Subacute Treatment: A Single-Center Series and Systematic Review of the Literature. World Neurosurg 2019; 134:e610-e615. [PMID: 31678312 DOI: 10.1016/j.wneu.2019.10.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The optimal timing for treatment of ruptured brain arteriovenous malformation (BAVM) is still controversial. The present study aims to determine safety of subacute BAVM management in clinically stable patients by identifying the rate of rebleeding. METHODS Patients presenting from 2000 to 2018 with ruptured BAVM who were scheduled for BAVM treatment at least 4 weeks after initial hemorrhage were included in the present study. After neurological rehabilitation of the patient and decreased hemorrhage-induced brain swelling, subacute treatment for the ruptured BAVM was carried out. Primary outcome of the present series was defined as treatment failure resulting from rehemorrhage caused by the ruptured BAVM in patients previously labeled eligible for subacute BAVM treatment. Additionally, we performed a systematic review of the contemporary peer-reviewed literature concerning treatment strategy in patients with ruptured BAVM. RESULTS Fifty-five patients suffering from ruptured BAVM were considered eligible for subacute BAVM treatment at our institution. No patient suffered from early rebleeding before definitive BAVM treatment in our institutional group. Our own patient data were then pooled with data from the literature, resulting in 166 patients suffering from ruptured BAVM who underwent subacute BAVM treatment. Of these, 1 patient (0.6%) suffered from rehemorrhage during the recovery period 130 days after initial BAVM rupture. CONCLUSIONS The present series and systematic review revealed a rehemorrhage rate of 0.6% in patients suffering from ruptured BAVM who underwent subacute treatment. Therefore, subacute treatment of patients with ruptured BAVM seems safe after application of rigorous treatment algorithms to sort out patients with higher risk for rehemorrhage.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany.
| | | | - Inja Ilic
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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Jin H, Lenck S, Krings T, Agid R, Fang Y, Li Y, Kostynskyy A, Tymianski M, Pereira VM, Radovanovic I. Interval angioarchitectural evolution of brain arteriovenous malformations following rupture. J Neurosurg 2019; 131:96-103. [PMID: 30052159 DOI: 10.3171/2018.2.jns18128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/23/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to describe changes in the angioarchitecture of brain arteriovenous malformations (bAVMs) between acute and delayed cerebral digital subtraction angiography (DSA) obtained after hemorrhage, and to examine bAVM characteristics predicting change. METHODS This is a retrospective study of a prospective institutional bAVM database. The authors included all patients with ruptured bAVMs who had DSA in both acute and delayed phases, with no interval treatment of their bAVM, between January 2000 and April 2017. The authors evaluated the existence or absence of angioarchitectural changes. Demographic data, radiological characteristics of hemorrhages, and angioarchitectural features of the bAVMs of the two patients' groups were analyzed. Univariate and multivariate logistic analyses were performed to identify predictors of angioarchitectural change. RESULTS A total of 42 patients were included in the series. Seventeen (40.5%) patients had angioarchitectural changes including bAVM only visible on the delayed DSA study (n = 8), spontaneous thrombosis of the AVM (n = 3), or alteration of the size or the opacification of the nidus (n = 6). The factors associated with angioarchitectural changes were a small nidus (3.8 ± 7.9 ml vs 6.1 ± 9.5 ml, p = 0.046), a superficial location (94.1% vs 5.9%, p = 0.016), and a single superficial draining vein (58.8% vs 24.0%, p = 0.029). CONCLUSIONS Angioarchitectural changes can be seen in 40% of ruptured bAVMs between the acute- and delayed-phase DSA. A small nidus, a superficial location, and a single superficial draining vein were statistically associated with the occurrence of angioarchitectural changes. These changes included either enlargement or spontaneous occlusion of the bAVM, as well as subsequent diagnosis of a bAVM following an initial negative DSA study.
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Affiliation(s)
- Hengwei Jin
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 2Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Stephanie Lenck
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Timo Krings
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ronit Agid
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yibin Fang
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 4Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Youxiang Li
- 2Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 3Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Alex Kostynskyy
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Tymianski
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
- 6Krembil Neuroscience Center, University Health Network, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
| | - Ivan Radovanovic
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
- 6Krembil Neuroscience Center, University Health Network, Toronto, Ontario, Canada
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Endovascular Therapy for Brainstem Arteriovenous Malformations. World Neurosurg 2018; 125:481-488. [PMID: 30149173 DOI: 10.1016/j.wneu.2018.08.099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/21/2022]
Abstract
Brainstem arteriovenous malformations (AVMs) represent ∼5% of all intracranial AVMs and carry a higher risk of hemorrhage than their supratentorial counterparts. There is a high and near-uniform mortality with initial and recurrent episodes of hemorrhage. Brainstem AVMs may also present symptomatically with focal neurologic deficits or hydrocephalus. Treatment is indicated for ruptured and symptomatic brainstem AVMs, as well as those possessing high-risk angioarchitectural features. Microsurgical resection and stereotactic radiosurgery are ideal therapeutic options when feasible. Embolization is most commonly used as adjunctive treatment before surgery or stereotactic radiosurgical irradiation. Preoperative embolization facilitates microsurgical resection and reduces intraoperative and postoperative hemorrhage rates. Use of embolization preradiosurgically helps to reduce nidal size, transforming a large lesion to a size amenable to radiosurgical intervention, increasing the probability of obliteration, decreasing procedural hemorrhage risk, stabilizing the lesion until radiotherapeutic effect achieves obliteration, and providing interval symptomatic resolution. Embolization may also be used effectively as stand-alone monotherapy for small lesions with 1 or 2 arterial feeders not supplying eloquent parenchyma. Although an extensive evidence base exists for clinical usefulness of stereotactic radiosurgery as monotherapy or in combination with other therapeutic modalities, only a few studies have reported specifically on obliteration and complication rates with monotherapeutic embolization in the treatment of brainstem AVMs. The potential role of embolization as monotherapy for brainstem AVMs is reviewed and discussed.
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Comparison of Grading Scales Regarding Perioperative Complications and Clinical Outcomes of Brain Arteriovenous Malformations After Endovascular Therapy-Multicenter Study. World Neurosurg 2017; 106:394-401. [PMID: 28712909 DOI: 10.1016/j.wneu.2017.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Several scales have been proposed for risk assessment and outcome determination in brain arteriovenous malformations treated by endovascular therapy. We aim to validate and compare the efficacy of these scales in predicting perioperative complications and clinical outcomes. METHODS We retrospectively reviewed brain arteriovenous malformations patients who underwent endovascular therapy at 4 centers in China from January 2012 to December 2015. The primary outcomes were complications, unfavorable outcome (mRS ≥ 3), and complete obliteration. Each patient was assessed using the Spetzler-Martin grading system (SM), Puerto Rico scale, Buffalo score, and arteriovenous malformation embocure score (AVMES). Correlation analysis was performed between primary outcomes incidence rate and the grades of each scale. The area under the receiver operating characteristic curve of these scales was calculated. Pairwise comparison of receiver operating characteristic curves was performed to compare the efficacy of the scales. RESULTS A total of 270 patients were included. Correlation analysis demonstrated that the complication rate increased with increasing grade in SM (P = 0.002), Puerto Rico scale (P = 0.014), and Buffalo score (P = 0.001); complete obliteration rate decreased with increasing grade in AVMES (P = 0.017); unfavorable outcome rate increased with increasing grade in the Puerto Rico scale (P = 0.005). The area under the receiver operating characteristic curve analysis showed statistical differences between the Puerto Rico score and SM (P = 0.047) in predicting complications and between the Puerto Rico score and SM (P = 0.008) in predicting unfavorable outcomes. The area under the curve of the AVMES in predicting complete obliteration was 0.757. CONCLUSIONS The Puerto Rico score predicts complications and unfavorable outcomes better than the SM. The AVMES scale has medium efficacy in predicting complete obliteration.
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Beecher JS, Lyon K, Ban VS, Vance A, McDougall CM, Whitworth LA, White JA, Samson D, Batjer HH, Welch BG. Delayed treatment of ruptured brain AVMs: is it ok to wait? J Neurosurg 2017; 128:999-1005. [PMID: 28686111 DOI: 10.3171/2017.1.jns16745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.
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Orning J, Amin-Hanjani S, Hamade Y, Du X, Hage ZA, Aletich V, Charbel F, Alaraj A. Increased prevalence and rupture status of feeder vessel aneurysms in posterior fossa arteriovenous malformations. J Neurointerv Surg 2015; 8:1021-4. [DOI: 10.1136/neurintsurg-2015-012005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/17/2015] [Indexed: 11/04/2022]
Abstract
BackgroundPosterior fossa arteriovenous malformations (AVMs) are considered to have a higher risk of poor outcome, as are AVMs with associated aneurysms. We postulated that posterior fossa malformations may be more prone to associated feeder vessel aneurysms, and to aneurysmal source of hemorrhage.ObjectiveTo examine the prevalence and hemorrhagic risk of posterior fossa AVM-associated feeder vessel aneurysms.MethodsA retrospective review of AVMs was performed with attention paid to location and presence of aneurysms. The hemorrhage status and origin of the hemorrhage was also reviewed.Results571 AVMs were analyzed. Of 90 posterior fossa AVMs, 34 (37.8%) had aneurysms (85% feeder vessel, 9% intranidal, 15% with both). Of the 481 supratentorial AVMs, 126 (26.2%) harbored aneurysms (65% feeder vessel, 29% intranidal, 6% both). The overall incidence of feeder aneurysms was higher in posterior fossa AVMs, which were evident in 34.4% of infratentorial AVMs compared to 18.5% of supratentorial malformations (p<0.01). The presence of intranidal aneurysms was similar in both groups (9.2% vs 8.8%). Feeder artery aneurysms were much more likely to be the source of hemorrhage in posterior fossa AVMs than in supratentorial AVMs (30% vs 7.6%, p<0.01).ConclusionsPosterior fossa AVMs are more prone to developing associated aneurysms, specifically feeder vessel aneurysms. Feeder vessel aneurysms are more likely to be the source of hemorrhage in the posterior fossa. As such, they may be the most appropriate targets for initial and prompt control by embolization or surgery due to their elevated threat.
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Malformations artérioveineuses et fistules durales artérioveineuses intracrâniennes en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1101-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Overall outcomes following early interventions for intracranial arteriovenous malformations with hematomas. J Clin Neurosci 2015; 23:95-100. [PMID: 26321303 DOI: 10.1016/j.jocn.2015.05.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/17/2015] [Accepted: 05/01/2015] [Indexed: 11/21/2022]
Abstract
We evaluated the timing and predictors of surgical intervention for intracranial arteriovenous malformations (AVM) with hematoma. A ruptured intracranial AVM with hematoma is an emergency condition, and the optimal timing for surgical intervention is not well understood. In addition, the outcome predictors of surgical intervention have rarely been reported. We identified and analyzed 78 patients treated with microsurgical resection for pathologically proven AVM at Louisiana State University Health in Shreveport from February 1992 to December 2004. All 78 patients were diagnosed with ruptured AVM before surgery. The independent variables, including patient demographics, timing of surgery, location of the AVM and comorbidities were analyzed to assess outcome. The results of this series revealed that surgical intervention after 48hours resulted in poor outcomes for patients with hematoma, following a ruptured AVM. Several other prognostic factors, including younger age (11-40years), Spetzler-Martin Grade I and II, and AVM in a supratentorial location, had significant positive effects on outcomes. However, hypertension, smoking, and a prior embolization showed significant negative effects on outcomes after surgery. The multiple logistic regression analyses also revealed that the timing of surgical intervention had a significant effect on outcomes in patients with hematoma following ruptured AVM. Early intervention is the key to success in these patients.
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Bruno CA, Meyers PM. Endovascular management of arteriovenous malformations of the brain. INTERVENTIONAL NEUROLOGY 2014; 1:109-23. [PMID: 25187772 DOI: 10.1159/000346927] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as 'primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.
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Affiliation(s)
- Charles A Bruno
- Departments of Radiology and Neurosurgery, Columbia University/New York Presbyterian Hospital, New York, N.Y., USA
| | - Philip M Meyers
- Neuroendovascular Services, Columbia University/New York Presbyterian Hospital, New York, N.Y., USA
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Cerebral microbleeds and macrobleeds: should they influence our recommendations for antithrombotic therapies? Curr Cardiol Rep 2014; 15:425. [PMID: 24122195 DOI: 10.1007/s11886-013-0425-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Intracerebral hemorrhage (ICH, or macrobleeds) and cerebral microbleeds-smaller foci of hemosiderin deposits commonly detected by magnetic resonance imaging of older adults with or without ICH-are both associated with an increased risk of future ICH. These hemorrhagic pathologies also share risk factors with ischemic thromboembolic conditions that may require antithrombotic therapy, requiring specialists in cardiology, internal medicine, and neurology to weigh the benefits vs hemorrhagic risks of antithrombotics in individual patients. This paper will review recent advances in our understanding of hemorrhage prone cerebrovascular pathologies with a particular emphasis on use of these markers in decision making for antithrombotic use.
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Alomari A, Rauch PJ, Orsaria M, Minja FJ, Chiang VL, Vortmeyer AO. Radiologic and histologic consequences of radiosurgery for brain tumors. J Neurooncol 2014; 117:33-42. [PMID: 24442402 DOI: 10.1007/s11060-014-1359-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
Progressively enlarging encephalopathic changes are now well-documented effects of gamma knife radiosurgery (GKRS) occurring ~3-30 months after treatment of both benign and malignant brain lesions. These changes can be variably associated with inflammatory demyelination and necrosis and/or recurrent tumor. While radiographic differentiation between encephalopathic changes and recurrent tumor is of high clinical relevance, confident interpretation of post-radiosurgery imaging changes can be challenging or even impossible in some cases. Gadolinium-enhanced MRI of these lesions reveals variable amounts of enhancing and non-enhancing components within these lesions that have not been clearly correlated with structural-pathologic change. The goal of this study is to characterize the histopathological changes associated with enhancing versus non-enhancing regions of GKRS-treated lesions. MRI images of patients with progressive, etiologically ambiguous brain lesions following GKRS were reviewed prior to explorative neurosurgery. Chosen for this study were lesions in which distinct areas of enhancement and non-enhancement of at least 5 mm in size could be identified (n = 16). Distinctly enhancing and non-enhancing areas were separately biopsied and histologically evaluated. Only cases with uniform histological results are presented in this study. Enhancing and non-enhancing areas in post GKRS lesions represent separate pathological changes. Radiographically enhancing areas correlate either with recurrent tumor growth or inflammatory demyelinating changes. Lack of radiographic enhancement correlates with coagulative necrosis if the sample is taken from the center of the lesion, or with reactive astrocytosis if the sample is taken from the periphery. Separate biopsy of enhancing and non-enhancing regions of post-GKRS encephalopathy was able to confirm that the pathologies in these areas are distinct. These findings allow for better-informed correlation of histological and radiological changes and a better understanding of post-treatment tissue pathology.
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Affiliation(s)
- Ahmed Alomari
- Neuropathology Program, Department of Pathology, Yale University School of Medicine, 416A Lauder Hall, 310 Cedar Street, New Haven, CT, 06520, USA
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Toma AK, Davagnanam I, Ganesan V, Brew S. Cerebral Arteriovenous Shunts in Children. Neuroimaging Clin N Am 2013; 23:757-70. [DOI: 10.1016/j.nic.2013.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Keefe K, Kebriaei M, Gard A, Patil AA. Intraventricular tissue plasminogen activator for intraventricular hemorrhage caused by an arteriovenous malformation. J Clin Neurosci 2013; 21:526-9. [PMID: 24134809 DOI: 10.1016/j.jocn.2013.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 04/14/2013] [Accepted: 04/19/2013] [Indexed: 11/20/2022]
Abstract
The use of thrombolytics delivered through an external ventricular drain has improved outcomes in intraventricular hemorrhage, a disease with a poor prognosis; however, presence of an arteriovenous malformation is generally considered a contraindication to thrombolytic use. Due do the high mortality with the current standard of care, thrombolytics should be considered as an acceptable treatment option despite the presence of an arteriovenous malformation in certain clinical situations. We review the available literature and present an additional patient to make the case for the use of thrombolytics for intraventricular hemorrhage from an arteriovenous malformation.
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Affiliation(s)
- Kelley Keefe
- Division of Neurosurgery, Department of Surgery, 982035 University of Nebraska Medical Center, Omaha, NE 68198-2035, USA.
| | - Meysam Kebriaei
- Division of Neurosurgery, Department of Surgery, 982035 University of Nebraska Medical Center, Omaha, NE 68198-2035, USA
| | - Andrew Gard
- Division of Neurosurgery, Department of Surgery, 982035 University of Nebraska Medical Center, Omaha, NE 68198-2035, USA
| | - Arun-Angelo Patil
- Division of Neurosurgery, Department of Surgery, 982035 University of Nebraska Medical Center, Omaha, NE 68198-2035, USA
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Functional reorganization oF the primary motor cortex in a patient with a large arteriovenous malFormation involving the precentral gyrus. Transl Neurosci 2013. [DOI: 10.2478/s13380-013-0122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractIt is known that the brain can compensate for deficits induced by acquired and developmental lesions through functional reorganization of the remaining parenchyma. Arteriovenous malformations (AVM) usually appear prenatally before a functional regional organization of the brain is fully established and patients generally do not present with motor deficits even when the AVM is located in the primary motor area indicating the redistribution of functions in cortical areas that are not pathologically altered. Here we present reorganization of the motor cortex in a patient with a large AVM involving most of the left parietal lobe and the paramedian part of the left precentral gyrus that is responsible for controlling the muscles of the lower limbs. Functional MRI showed that movements of both the right and left feet activated only the primary motor cortex in the right hemisphere, while there was no activation in the left motor cortex. This suggests that complete ipsilateral control over the movements of the right foot had been established in this patient. A reconstruction of the corticospinal tract using diffusion tensor imaging showed a near-complete absence of corticospinal fibers from the part of the left precentral gyrus affected by the AVM. From this clinical presentation it can be concluded that full compensation of motor deficits had occurred by redistributing function to the corresponding motor area of the contralateral
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