Artikel
Microsurgical resection of Spetzler-Martin grade 1 and 2 unruptured brain arteriovenous malformations results in lower long-term morbidity than conservative management – results of 97 cases
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Autoren
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Hans-Jakob Steiger
- Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
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Benjamin Rohn
- Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
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Igor Fischer
- Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
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Nima Etminan
- Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
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Daniel Hänggi
- Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
| Veröffentlicht: | 2. Juni 2015 |
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Gliederung
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Objective: The therapeutic benefits of intervention for unruptured brain arteriovenous malformations (AVM) remain unclear. The purpose of the present study was to analyze functional outcome after microsurgical resection and to define subgroups with particularly favourable and unfavourable treatment outcome, compared to the natural course.
Method: A series of 97 patients who underwent treatment for an unruptured brain AVM between July 1992 and June 2014 were included in the analysis. Spetzler-Martin (SM) grades were 1 in 25 patients (26%), 2 in 44 (45%), 3 in 22 (23%) and 4 in 6 (6%). 47 AVM were embolized pre-operatively (48%). Average follow-up was 3.5 years. Early outcome was defined in terms of any additional deficit at the time of discharge and late outcome was quantified as morbidity >mRS1 at the time of the last follow-up and as the expected sum of lost Quality Adjusted Life Years (QALY) until the age of 70. For comparison, the natural risk of becoming disabled was modeled on the basis of cohorts from the ARUBA trial and the Scottish Audit on Intracranial Vascular Malformations.
Results: Discharge morbidity with SM1&2, 3, 4 occurred in 16%, 36% and 67%, respectively, and permanent morbidity >mRS1 in 4.3%, 18% and 50%, respectively. Permanent morbidity (mRS>1) was recorded in 7% of the patients younger than 39 years and 15% of the older group. On average, loss of QALY due to treatment amounted to 1.4 years, 0.52 year with SM 1&2, 2.5 years with grade 3 and to 7.3 years with grade 4. Stratified for age, treatment was associated on average with a loss of 1.0 QALY in patients younger than 39 years and 2.1 years in older patients. The overall treatment related loss of 1.4 QALY was met by the modeled natural course after 7.3 - 11.5 years. For SM 1&2, the treatment related loss of 0.52 QALY was met after 3.8 - 4.5 years. For SM 3, the loss of 2.5 QALY was met by the natural risk only after 14.1 - 23.4 years and for SM 4 the treatment-related loss of 7.3 QALY was never met by the natural risk.
Conclusions: Microsurgical resection alone or in combination with endovascular embolization of unruptured AVM Spetzler-Martin grade 1 and 2 produced a more favourable outcome than the natural course, in contrast to resection of grade 3&4 AVM. Patients younger than 39 years fared better than older patients.
