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Timing of surgery for ruptured supratentorial arteriovenous malformations

  • Original Article - Vascular
  • Published:
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Abstract

Background

There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome.

Objective

To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery.

Methods

We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2–4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome).

Results

Age over 40 years (OR 18.4; 95% CI 1.9–172.1; p = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1–89.2; p = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8–94.4; p = 0.011), and over 400 cm3 bleeding during surgery (OR 11.5; 95% CI 1.5–86.6; p = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6–1524.9; p = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4–829.9; p = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6–332.6; p = 0.007), and over 400 cm3 bleeding during surgery (OR 35.3; 95% CI 1.7–748.7; p = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2–55.7; p = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3–24.3; p = 0.019), and over 400 cm3 bleeding during surgery (OR 5.8; 95% CI 1.2–27.3; p = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome.

Conclusions

Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.

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Funding

The Finnish government provided financial support (Finnish government grant for academic health research #TYH2017235). First author (A.H.) was awarded a scholarship for his PhD program from C. Ehmrooth Fellowship (Fondation de Luxembourg). The sponsors had no role in the design or conduct of this research.

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Authors and Affiliations

  1. Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland

    Ahmad Hafez, Elias Oulasvirta, Päivi Koroknay-Pál, Mika Niemelä, Juha Hernesniemi & Aki Laakso

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  1. Ahmad Hafez
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  2. Elias Oulasvirta
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  3. Päivi Koroknay-Pál
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  4. Mika Niemelä
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Corresponding author

Correspondence to Ahmad Hafez.

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Conflict of interest

None.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Comments

We have here a study from a renowned senior surgeon and an experienced group regarding early surgery approach to ruptured intracranial AVMs. The analysis is done on 59 patients culled from a total experience of 805 patients. It is a fractional sample of the overall group, but this is because careful steps were taken to ensure a complete dataset in analyzed patients. The data is instructive even though it is a small subset of the Helsinki AVM experience.

The raw data is impressive, no doubt because of the quality of this highly experienced team and center, and their ability to transfer patients quickly from throughout Finland. Mean time to surgery was 2 days. Complete excision at first surgery was achieved in 96% of patients. Mortality was 15%. Deep perforators, high Hunt-Hess grade before surgery (note that they have used Hunt and Hess grading for AVMs in the absence of a truly dedicated AVM hemorrhage acuity grading system), age over 40, hydrocephalus, amount of bleeding during surgery, and AVM-related aneurysms were associated with an increased likelihood of poor surgical outcomes. Importantly, neither time to surgery nor embolization before surgery were associated with significant differences in outcome.

This study impacts the practice of AVM surgery in several important ways. Unlike aneurysmal subarachnoid hemorrhage, in this series a policy of early AVM surgery is neither better nor worse than a policy of delayed surgery, except of course where life-threatening ICH and mass effect are present, and early surgery is thus mandated. The study also codifies that risk factors which AVM surgeons know intuitively to be negative predictors of outcome, like excessive bleeding, deep feeders, poor patient condition and the others outlined above, are validated by this analysis.

The only reservation about this paper is that of course this is a tiny subset of the extensive Helsinki experience. However, we can understand why they chose to do it this way, to obtain the best possible dataset, and we accept and recommend the article as a quality observation of many things, but especially that early AVM surgery is reasonable and can be associated with similar outcomes to delayed surgery if the team and facility is available and the surgeon elects this practice.

Christopher M. Loftus,

Philadelphia, PA, USA

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Hafez, A., Oulasvirta, E., Koroknay-Pál, P. et al. Timing of surgery for ruptured supratentorial arteriovenous malformations. Acta Neurochir 159, 2103–2112 (2017). https://doi.org/10.1007/s00701-017-3315-9

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  • DOI: https://doi.org/10.1007/s00701-017-3315-9

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