Multi-Stage Treatment for Spetzler–Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Data Collection
2.3. Endovascular Treatment
2.4. Microsurgical Resection
2.5. Follow-Up and Outcomes
2.6. Statistical Analysis
3. Results
3.1. Baseline Characteristics
3.2. Treatment and Follow-Up
3.3. Outcomes
4. Discussion
4.1. Risk Factors
4.2. Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Characteristics | Unruptured AVMs | Ruptured AVMs | p Value |
---|---|---|---|
Number of patients | 163/250 (65.2) | 87/250 (34.8) | |
Age in years ‡ | 55.12 (14.43) | 58.49 (19.15) | 0.001 * |
Age (years) | 0.006 * | ||
0–19 | 1(0.6) | 0 | |
20–39 | 22 (13.5) | 16 (18.4) | |
40–59 | 77 (47.2) | 31 (35.6) | |
60–79 | 56 (34.4) | 25 (28.7) | |
≥80 | 7 (4.3) § | 15 (17.2) § | |
Sex | 0.803 | ||
Male | 91 (55.8) | 50 (57.5) | |
Female | 72 (44.2) | 37 (42.5) | |
AVM grade | |||
SM III (Ponce B) | 95 (58.2) | 55 (63.2) | 0.743 |
SM IV | 56 (34.4) | 26 (29.9) | |
SM V | 12 (7.4) | 6 (6.9) | |
Ponce C | 68 (41.7) | 32 (36.8) | 0.448 |
Nidus size (cm) | 0.021 * | ||
<3 | 19 (11.7) § | 22 (25.3) § | |
3–6 | 120 (73.6) | 54 (62.1) | |
>6 | 24 (14.7) | 11 (12.6) | |
Eloquent area | 127 (77.9) | 62 (71.3) | 0.244 |
Deep venous drainage | 108 (66.3) | 72 (82.8) | 0.006 * |
Location | |||
Supratentorial | 151 (92.6) | 68 (78.2) | 0.001 * |
Infratentorial | 12 (7.4) | 19 (21.8) | |
AVM side | 0.001 * | ||
Right | 81 (49.7) | 38 (43.7) | |
Left | 81 (49.7) | 40 (46) | |
Midline | 1 (0.6) § | 9 (10.3) § | |
Presence of aneurysms | 26 (16) | 31 (35.6) | 0.001 * |
Aneurysm type | 0.661 | ||
Flow-related arterial | 25 (96.2) | 29 (93.5) | |
Intranidal | 1 (3.8) | 2 (6.5) | |
Presence of venous varix | 7 (4.3) | 5 (5.7) | 0.410 |
mRS score ≥ 3 at presentation | 3 (1.8) | 22 (25.3) | 0.001 * |
Number of embolizations ‡ | 5.9 (5.684) | 5.2 (5.133) | 0.338 |
Percentage devascularization | 0.09 | ||
<50 | 11 (6.7) | 13 (14.9) | |
50–80 | 39 (23.9) | 16 (18.4) | |
>80 | 113 (69.4) | 58 (66.7) | |
mRS score ≥ 3 after embolization | 9 (5.5) | 25 (28.7) | 0.001 * |
Number of surgeries ‡ | 1.09 (0.281) | 1.15 (0.390) | 0.181 |
mRS score ≥ 3 after surgery | 37 (22.7) | 33 (37.9) | 0.011 * |
Total resection | 132 (81) | 58 (66.7) | 0.012 * |
Preoperative SRS | 16 (9.8) | 10 (11.5) | 0.679 |
mRS score ≥ 3 at last follow-up | 21 (12.9) | 27 (31) | 0.001 * |
mRS score shift from ≤2 to ≥3 | 18 (11) | 11 (12.6) | 0.707 |
Percentage Devascularization | ||||
---|---|---|---|---|
Characteristics | <50% | 50–80% | >80% | p Value |
Number of patients | 24/250 (9.6) | 55/250 (22) | 171/250 (68.4) | |
AVM grade | 0.003 * | |||
III (Ponce B) | 13 (54.2) | 31 (56.4) | 106 (62) | |
IV | 5 (20.8) | 23 (41.8) | 54 (31.6) | |
V | 6 (25) § | 1 (1.8) | 11 (6.4) | |
Ponce C | 11(45.8%) | 24 (43.6%) | 65 (38%) | 0.63 |
Nidus size (cm) | 0.004 * | |||
<3 | 6 (25) | 4 (7.2) | 31 (18.1) | |
3–6 | 10 (41.7) § | 42 (76.4) | 122 (71.4) | |
>6 | 8 (33.3) § | 9 (16.4) | 18 (10.5) | |
Brain eloquent area | 20 (83.3) | 42 (76.4) | 127 (74.3) | 0.619 |
Deep venous drainage | 19 (79.2) | 33 (60) | 128 (74.9) | 0.073 |
AVM status | 0.09 | |||
Unruptured | 11 (45.8) | 39 (70.9) | 113 (66.1) | |
Ruptured | 13 (54.2) | 16 (29.1) | 58 (33.9) | |
Location | 0.032 * | |||
Supratentorial | 17 (70.8) § | 49 (89.1) | 153 (89.5) | |
Infratentorial | 7 (29.2) § | 6 (10.9) | 18(10.5) | |
AVM side | 0.018 * | |||
Right | 16 (66.7) | 22 (40) | 81 (47.4) | |
Left | 5 (20.8) § | 31 (56.4) | 85 (49.7) | |
Midline | 3 (12.5) | 2 (3.6) | 5 (2.9) | |
Presence of aneurysms | 7 (29.2) | 11 (20) | 39(22.8) | 0.671 |
Presence of venous varix | 4 (16.7) § | 4 (7.3) | 4(2.3) § | 0.006 * |
Logistic Regressions | Univariate | Multivariate | ||||
---|---|---|---|---|---|---|
Predictors | OR | 95% CI | p Value | OR | 95% CI | p Value |
Age (years) | ||||||
0–19 | - | - | - | |||
20–39 | 0.449 | 0.151–1.333 | 0.149 | |||
40–59 | 0.279 | 0.132–0.591 | 0.001 * | 0.654 | 0.264–1.625 | 0.361 |
60–79 | 1.651 | 0.864–3.155 | 0.129 | |||
≥80 | 9.985 | 3.893–25.613 | 0.001 * | 9.398 | 2.689–32.843 | 0.001 * |
Female sex | 0.907 | 0.479–1.716 | 0.764 | |||
mRS score ≥ 3 at presentation | 21.402 | 7.895–58.017 | 0.001 * | 30.376 | 8.106–113.831 | 0.001 * |
Location | ||||||
Supratentorial | 0.370 | 0.163–0.836 | 0.017 * | 0.404 | 0.116–1.414 | 0.156 |
Infratentorial | 2.705 | 1.196–6.119 | 0.017 * | 2.473 | 0.707–8.644 | 0.156 |
Side | ||||||
Left | 0.577 | 0.302–1.100 | 0.095 | |||
Right | 1.126 | 0.600–2.114 | 0.711 | |||
Midline | 7.071 | 1.911–26.162 | 0.003 * | 4.678 | 0.711–30.759 | 0.108 |
AVM grade | ||||||
SM III (Ponce B) | 0.743 | 0.394–1.402 | 0.360 | |||
SM IV | 1.446 | 0.754–2.771 | 0.267 | |||
SM V | 0.831 | 0.231–2.994 | 0.777 | |||
Ponce C | 1.345 | 0.713–2.537 | 0.360 | |||
Nidus size (cm) | ||||||
<3 | 0.682 | 0.269–1.727 | 0.419 | |||
3–6 | 1.076 | 0.539–2.145 | 0.836 | |||
>6 | 1.296 | 0.548–3.065 | 0.554 | |||
Eloquent brain area | 0.961 | 0.464–1.990 | 0.914 | |||
Deep venous drainage | 1.058 | 0.522–2.146 | 0.875 | |||
Ruptured AVM | 3.043 | 1.596–5.801 | 0.001 * | 0.498 | 0.176–1.409 | 0.189 |
Presence of aneurysms | 3.586 | 1.827–7.041 | 0.001 * | 2.028 | 0.846–4.862 | 0.113 |
Presence of venous varix | 1.430 | 0.372–5.494 | 0.603 | |||
Percentage devascularization | ||||||
<50 | 1.460 | 0.547–3.902 | 0.450 | |||
50–80 | 1.068 | 0.504–2.263 | 0.865 | |||
>80 | 0.808 | 0.416–1.567 | 0.527 | |||
Preoperative SRS | 0.744 | 0.244–2.269 | 0.603 |
Logistic Regressions | Univariate | Multivariate | ||||
---|---|---|---|---|---|---|
Predictors | OR | 95% CI | p Value | OR | 95% CI | p Value |
Age (years) | ||||||
0–19 | - | |||||
20–39 | 0.634 | 0.298–1.350 | 0.238 | |||
40–59 | 1.086 | 0.603–1.955 | 0.783 | |||
60–79 | 2.598 | 1.268–5.324 | 0.009 * | 2.155 | 0.986–4.708 | 0.054 |
≥80 | 0.222 | 0.091–0.545 | 0.001 * | 0.255 | 0.093–0.703 | 0.008 * |
Female sex | 0.928 | 0.517–1.664 | 0.802 | |||
mRS score ≥ 3 at presentation | 0.429 | 0.181–1.012 | 0.053 | |||
Location | ||||||
Supratentorial | 0.716 | 0.281–1.826 | 0.485 | |||
Infratentorial | 1.396 | 0.548–3.561 | 0.485 | |||
Side | ||||||
Left | 1.430 | 0.795–2.571 | 0.232 | |||
Right | 0.677 | 0.378–1.212 | 0.189 | |||
Midline | 0.784 | 0.162–3.799 | 0.763 | |||
AVM grade | ||||||
SM III (Ponce B) | 2.953 | 1.624–5.369 | 0.001 * | - | - | - |
SM IV | 0.414 | 0.228–0.752 | 0.004 * | - | - | - |
SM V | 0.465 | 0.172–1.260 | 0.132 | - | - | - |
Ponce C | 0.390 | 0.223–0.682 | 0.001 * | - | - | - |
Nidus size (cm) | ||||||
<3 | 1.650 | 0.691–3.943 | 0.260 | |||
3–6 | 1.607 | 0.874–2.955 | 0.127 | |||
>6 | 0.306 | 0.145–0.642 | 0.002 * | 0.241 | 0.103–0.565 | 0.001 * |
Eloquent brain area | 1.465 | 0.766–2.802 | 0.248 | |||
Deep venous drainage | 0.373 | 0.173–0.807 | 0.012 * | 0.332 | 0.142–0.779 | 0.011 * |
Ruptured AVM | 0.470 | 0.260–0.850 | 0.013 * | 0.680 | 0.345–1.342 | 0.266 |
Presence of aneurysms | 0.851 | 0.432–1.676 | 0.641 | |||
Presence of venous varix | 0.945 | 0.247–3.608 | 0.934 | |||
Percentage devascularization | ||||||
<50 | 0.327 | 0.138–0.776 | 0.011 * | 0.438 | 0.165–1.165 | 0.098 |
50–80 | 1.552 | 0.728–3.308 | 0.255 | |||
>80 | 1.225 | 0.663–2.264 | 0.516 | |||
Preoperative SRS | 1.367 | 0.492–3.797 | 0.549 |
Deficit | Post-Embolization | Post-Surgery | Last Follow-Up |
---|---|---|---|
Disabling deficit mRS score ≥ 3 | 15 (6.7) | 49 (21.8) | 29 (12.8) |
Non-disabling deficit mRS score ≤2 | 54 (24) | 88 (39.1) | 91 (40.4) |
Total | 69 (27.6) | 137 (60.9) | 120 (53.3) |
Logistic Regressions | Univariate | Multivariate | ||||
---|---|---|---|---|---|---|
Predictors | OR | 95% CI | p Value | OR | 95% CI | p Value |
Age (years) | ||||||
0–19 | - | - | - | |||
20–39 | 0.202 | 0.027–1.539 | 0.123 | |||
40–59 | 0.359 | 0.139–0.927 | 0.034 * | 0.597 | 0.211–1.685 | 0.330 |
60–79 | 1.925 | 0.847–4.379 | 0.118 | |||
≥80 | 5.133 | 1.865–14.131 | 0.002 * | 4.061 | 1.269–12.995 | 0.018 * |
Female sex | 0.789 | 0.343–1.815 | 0.577 | |||
mRS score ≥ 3 at presentation | - | - | - | |||
Location | ||||||
Supratentorial | 0.257 | 0.101–0.658 | 0.005 * | 0.271 | 0.098–0.753 | 0.012 * |
Infratentorial | 3.884 | 1.520–9.923 | 0.005 * | 3.689 | 1.328–10.247 | 0.012 * |
Side | ||||||
Left | 0.437 | 0.182–1.045 | 0.063 | |||
Right | 1.573 | 0.692–3.577 | 0.279 | |||
Midline | 4.043 | 0.978–16.714 | 0.054 | |||
AVM grade | ||||||
SM III (Ponce B) | 0.448 | 0.197–1.022 | 0.056 | |||
SM IV | 2.246 | 0.990–5.097 | 0.053 | |||
SM V | 1.083 | 0.235–5.000 | 0.918 | |||
Ponce C | 2.230 | 0.979–5.081 | 0.056 | |||
Nidus size (cm) | ||||||
<3 | 0.184 | 0.024–1.398 | 0.102 | |||
3–6 | 1.515 | 0.583–3.938 | 0.394 | |||
>6 | 1.540 | 0.540–4.393 | 0.420 | |||
Eloquent brain area | 1.085 | 0.415–2.838 | 0.868 | |||
Deep venous drainage | 1.062 | 0.426–2.650 | 0.897 | |||
Ruptured AVM | 1.193 | 0.517–2.755 | 0.679 | |||
Presence of aneurysms | 2.838 | 1.222–6.592 | 0.015 * | 1.728 | 0.683–4.369 | 0.248 |
Presence of venous varix | 0.775 | 0.096–6.254 | 0.811 | |||
Percentage devascularization | ||||||
<50 | 0.350 | 0.045–2.701 | 0.314 | |||
50–80 | 0.829 | 0.297–2.309 | 0.719 | |||
>80 | 1.611 | 0.621–4.184 | 0.327 | |||
Preoperative SRS | 0.318 | 0.041–2.453 | 0.272 |
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Alfter, M.; Albiña-Palmarola, P.; Cimpoca, A.; Díaz-Peregrino, R.; Jans, P.; Ganslandt, O.; Kühne, D.; Henkes, H. Multi-Stage Treatment for Spetzler–Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients. J. Clin. Med. 2023, 12, 5990. https://doi.org/10.3390/jcm12185990
Alfter M, Albiña-Palmarola P, Cimpoca A, Díaz-Peregrino R, Jans P, Ganslandt O, Kühne D, Henkes H. Multi-Stage Treatment for Spetzler–Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients. Journal of Clinical Medicine. 2023; 12(18):5990. https://doi.org/10.3390/jcm12185990
Chicago/Turabian StyleAlfter, Marcel, Pablo Albiña-Palmarola, Alexandru Cimpoca, Roberto Díaz-Peregrino, Paul Jans, Oliver Ganslandt, Dietmar Kühne, and Hans Henkes. 2023. "Multi-Stage Treatment for Spetzler–Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients" Journal of Clinical Medicine 12, no. 18: 5990. https://doi.org/10.3390/jcm12185990
APA StyleAlfter, M., Albiña-Palmarola, P., Cimpoca, A., Díaz-Peregrino, R., Jans, P., Ganslandt, O., Kühne, D., & Henkes, H. (2023). Multi-Stage Treatment for Spetzler–Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients. Journal of Clinical Medicine, 12(18), 5990. https://doi.org/10.3390/jcm12185990