Natural History and Management Outcomes of Patients with Ruptured Spetzler-Martin Grade Ⅳ and Ⅴ Brain Arteriovenous Malformations

Saturday, May 4, 2024

4:42 PM – 4:49 PM CT

Location: N427d

Presenting Author(s)

Shahab Aldin Sattari, MD

Postdoc Research Fellow
Johns Hopkins

Co-Author(s)

JF

James Feghali, MD

Resident
Johns Hopkins, United States
Judy Huang, MD (she/her/hers)

Professor of Neurosurgery
Department of Neurosurgery, The Johns Hopkins University School of Medicine
Baltimore, MD, US
aH

alice Hung, MD

Resident
Johns Hopkins
Baltimore, Maryland, United States
rT

rafael Tamargo, MD

Professor of Neurosurgery
Department of Neurosurgery, Johns Hopkins Hospital
Baltimore, MD, United States
Risheng xu, MD PhD

Professor of Neurosurgery
Department of Neurosurgery, Johns Hopkins Hospital
Baltimore, Maryland, United States
Wuyang Yang, MD (he/him/his)

Resident
Johns Hopkins
Baltimore, Maryland, United States

Disclosure(s):

Shahab Aldin Sattari, MD: No financial relationships to disclose

Judy Huang, MD: No financial relationships to disclose

Introduction: Natural history of ruptured high grade (Spetzler-Martin grade Ⅳ and Ⅴ) brain arteriovenous malformations (bAVMs) is under-reported due to scarcity of this pathology, and decision-making for these patients remains unclarified.This study aim to elucidate management outcomes in ruptured high grade AVM patients

Methods: Patients harboring ruptured high-grade bAVMs were retrieved from the institutional database spanning 1990-2020. Outcomes were annual hemorrhage risk in those untreated and after treatment, follow-up hemorrhage rate, obliteration, follow-up modified Rankin Scale (mRS) >2, worsened mRS, and mortality.

Results: After reviewing 1066 patients, 84 patients harboring ruptured high-grade bAVMs were included. For cortical bAVMs, the annual risk of hemorrhage during natural history was 2.68%. Surgery decreased the risk to 0.74%, while radiosurgery increased the risk to 5.35%, and embolization increased the risk to 16.96%. For deep-seated bAVMs, the annual risk of hemorrhage during natural history was 8.37%. Radiosurgery decreased the risk to 3.11%, surgery decreased the risk to 5.25%, and embolization increased the risk to 22.33%. Poisson regression analysis demonstrated that embolization only increased the hemorrhage in cortical bAVMs (rate ratio=4.745 (1.365-12.819), p=0.005) and deep-seated bAVMs (rate ratio=6.290 (0.997-21.932), p=0.013). Logistic regression analysis showed that surgery (odds ratio=52.000 (8.083-1046.127), p=0.004) and radiosurgery (odds ratio=11.142 (1.804-217.650), p=0.029) were the predictors of obliteration in cortical and deep-seated bAVMs, respectively. The proportions of patients having worsened mRS, follow-up mRS>2, and mortality were similar between conservative and treatment groups.

Conclusion : Natural history of cortical ruptured high-grade bAVMs bears similar risk to that of incidental bAVMs, whereas deep-seated ruptured high-grade bAVMs have an increased risk of hemorrhage. With prudent patient selection, for cortical bAVMs, surgery might be a viable option to obliterate the bAVM and reduce hemorrhagic risk, with need to weigh the impact on functional status. Radiosurgery might be beneficial to lower hemorrhagic risk in deep-seated bAVMs. Embolization as a single modality should be avoided as it increases hemorrhagic risk to exceed the risk associated with natural history.