Skip to main content
NCBI home page
Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 1998 Oct;65(4):547–554. doi: 10.1136/jnnp.65.4.547

Significance of factors contributing to surgical complications and to late outcome after elective surgery of cerebral arteriovenous malformations

C Schaller 1, J Schramm 1, D Haun 1
PMCID: PMC2170302  PMID: 9771782

Abstract

OBJECTIVES—This study focuses on the relevance of size, eloquence, type of venous drainage, the Spetzler-Martin scale as a whole, and other factors, such as rupture of cerebral arteriovenous malformations (AVMs) for the prediction of neurological deficits in the context of microsurgical AVM removal.
METHODS—One hundred and fifty patients with AVMs, whose data were retrieved from a prospectively employed computerised data bank were included. Seventeen patients (11.3%) underwent preoperative embolisation. According to the Spetzler-Martin scale they were graded as follows: 22.0% grade I, 32.0% grade II, 29.3% grade III, 14.0% grade IV, and 2.7% grade V. Intracerebral haemorrhage was present in 39.0%. The AVMs were <3 cm in 52.0%, 3-6 cm in 43.3% and >6 cm in 4.7%; 59.3% of the AVMs were eloquently located and 29.3% had deep venous drainage (DVD). Follow up information was assessed 6 months after surgery in all but one patient, who died. The applied statistical test was χ2.
RESULTS—Surgical morbidity was 15.3%. Early new deficits were noted in 39.3%, permanent new deficits in 10.6%, being significant (major) in 7.3%. The ocurrence of permanent deficits correlated significantly with size, deep venous drainage, and the Spetzler-Martin scale. There was statistical evidence for a trend in risk of poor surgical outcome across the three categories non-eloquent, "less eloquent" (for example, visual cortex) and "highly eloquent" (brainstem, basal ganglia, or precentral cortex) with the last being associated with the highest risk for permanent neurological compromise.
CONCLUSION—"Eloquence" of the Spetzler-Martin scale should be divided into "highly eloquent" and "less eloquent", which is important for risk analysis of the treatment of asymptomatic and deep seated AVMs and for future trials comparing various treatment modalities. In addition, resection of eloquent AVMs v non-eloquent ones is significantly associated with higher surgical morbidity.



Full Text

The Full Text of this article is available as a PDF (154.2 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Auger R. G., Wiebers D. O. Management of unruptured intracranial arteriovenous malformations: a decision analysis. Neurosurgery. 1992 Apr;30(4):561–569. doi: 10.1227/00006123-199204000-00015. [DOI] [PubMed] [Google Scholar]
  2. Batjer H. H., Devous M. D., Sr, Seibert G. B., Purdy P. D., Bonte F. J. Intracranial arteriovenous malformation: relationship between clinical factors and surgical complications. Neurosurgery. 1989 Jan;24(1):75–79. doi: 10.1227/00006123-198901000-00012. [DOI] [PubMed] [Google Scholar]
  3. Brown R. D., Jr, Wiebers D. O., Forbes G. S. Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions. J Neurosurg. 1990 Dec;73(6):859–863. doi: 10.3171/jns.1990.73.6.0859. [DOI] [PubMed] [Google Scholar]
  4. Brown R. D., Jr, Wiebers D. O., Forbes G., O'Fallon W. M., Piepgras D. G., Marsh W. R., Maciunas R. J. The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg. 1988 Mar;68(3):352–357. doi: 10.3171/jns.1988.68.3.0352. [DOI] [PubMed] [Google Scholar]
  5. Brown R. D., Jr, Wiebers D. O., Torner J. C., O'Fallon W. M. Frequency of intracranial hemorrhage as a presenting symptom and subtype analysis: a population-based study of intracranial vascular malformations in Olmsted Country, Minnesota. J Neurosurg. 1996 Jul;85(1):29–32. doi: 10.3171/jns.1996.85.1.0029. [DOI] [PubMed] [Google Scholar]
  6. Dawson R. C., 3rd, Tarr R. W., Hecht S. T., Jungreis C. A., Lunsford L. D., Coffey R., Horton J. A. Treatment of arteriovenous malformations of the brain with combined embolization and stereotactic radiosurgery: results after 1 and 2 years. AJNR Am J Neuroradiol. 1990 Sep-Oct;11(5):857–864. [PMC free article] [PubMed] [Google Scholar]
  7. Fisher W. S., 3rd Decision analysis: a tool of the future: an application to unruptured arteriovenous malformations. Neurosurgery. 1989 Jan;24(1):129–135. doi: 10.1227/00006123-198901000-00025. [DOI] [PubMed] [Google Scholar]
  8. Friedman W. A., Blatt D. L., Bova F. J., Buatti J. M., Mendenhall W. M., Kubilis P. S. The risk of hemorrhage after radiosurgery for arteriovenous malformations. J Neurosurg. 1996 Jun;84(6):912–919. doi: 10.3171/jns.1996.84.6.0912. [DOI] [PubMed] [Google Scholar]
  9. Friedman W. A., Bova F. J., Mendenhall W. M. Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome. J Neurosurg. 1995 Feb;82(2):180–189. doi: 10.3171/jns.1995.82.2.0180. [DOI] [PubMed] [Google Scholar]
  10. Gómez-Tortosa E., Sychra J. J., Martin E. M., Arteaga M., Gaviria M., Pavel D. G., Dujovny M., Ausman J. I. Postoperative cognitive and single photon emission computed tomography assessment of patients with resection of perioperative high-risk arteriovenous malformations. Neurosurgery. 1995 Mar;36(3):447–458. doi: 10.1227/00006123-199503000-00002. [DOI] [PubMed] [Google Scholar]
  11. Hamilton M. G., Spetzler R. F. The prospective application of a grading system for arteriovenous malformations. Neurosurgery. 1994 Jan;34(1):2–7. [PubMed] [Google Scholar]
  12. Heros R. C., Korosue K., Diebold P. M. Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery. 1990 Apr;26(4):570–578. doi: 10.1097/00006123-199004000-00003. [DOI] [PubMed] [Google Scholar]
  13. Heros R. C., Korosue K. Radiation treatment of cerebral arteriovenous malformations. N Engl J Med. 1990 Jul 12;323(2):127–129. doi: 10.1056/NEJM199007123230211. [DOI] [PubMed] [Google Scholar]
  14. Heros R. C., Tu Y. K. Unruptured arteriovenous malformations: a dilemma in surgical decision making. Clin Neurosurg. 1986;33:187–236. [PubMed] [Google Scholar]
  15. Hubschmann O. R., Krieger A. J. The perivenous technique of resection of arteriovenous malformations from vital areas of the brain. Surg Neurol. 1987 Apr;27(4):323–330. doi: 10.1016/0090-3019(87)90006-1. [DOI] [PubMed] [Google Scholar]
  16. Jomin M., Lesoin F., Lozes G. Prognosis for arteriovenous malformations of the brain in adults based on 150 cases. Surg Neurol. 1985 Apr;23(4):362–366. doi: 10.1016/0090-3019(85)90207-1. [DOI] [PubMed] [Google Scholar]
  17. Kashiwagi S., van Loveren H. R., Tew J. M., Jr, Wiot J. G., Weil S. M., Lukin R. A. Diagnosis and treatment of vascular brain-stem malformations. J Neurosurg. 1990 Jan;72(1):27–34. doi: 10.3171/jns.1990.72.1.0027. [DOI] [PubMed] [Google Scholar]
  18. Kihlström L., Guo W. Y., Karlsson B., Lindquist C., Lindqvist M. Magnetic resonance imaging of obliterated arteriovenous malformations up to 23 years after radiosurgery. J Neurosurg. 1997 Apr;86(4):589–593. doi: 10.3171/jns.1997.86.4.0589. [DOI] [PubMed] [Google Scholar]
  19. Kondziolka D., McLaughlin M. R., Kestle J. R. Simple risk predictions for arteriovenous malformation hemorrhage. Neurosurgery. 1995 Nov;37(5):851–855. doi: 10.1227/00006123-199511000-00001. [DOI] [PubMed] [Google Scholar]
  20. Lawton M. T., Hamilton M. G., Spetzler R. F. Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery. 1995 Jul;37(1):29–36. doi: 10.1227/00006123-199507000-00004. [DOI] [PubMed] [Google Scholar]
  21. Luessenhop A. J., Gennarelli T. A. Anatomical grading of supratentorial arteriovenous malformations for determining operability. Neurosurgery. 1977 Jul-Aug;1(1):30–35. doi: 10.1227/00006123-197707000-00007. [DOI] [PubMed] [Google Scholar]
  22. Luessenhop A. J., Rosa L. Cerebral arteriovenous malformations. Indications for and results of surgery, and the role of intravascular techniques. J Neurosurg. 1984 Jan;60(1):14–22. doi: 10.3171/jns.1984.60.1.0014. [DOI] [PubMed] [Google Scholar]
  23. Malik G. M., Umansky F., Patel S., Ausman J. I. Microsurgical removal of arteriovenous malformations of the basal ganglia. Neurosurgery. 1988 Aug;23(2):209–217. doi: 10.1227/00006123-198808000-00014. [DOI] [PubMed] [Google Scholar]
  24. Mathis J. A., Barr J. D., Horton J. A., Jungreis C. A., Lunsford L. D., Kondziolka D. S., Vincent D., Pentheny S. The efficacy of particulate embolization combined with stereotactic radiosurgery for treatment of large arteriovenous malformations of the brain. AJNR Am J Neuroradiol. 1995 Feb;16(2):299–306. [PMC free article] [PubMed] [Google Scholar]
  25. Meyer B., Stangl A. P., Schramm J. Association of venous and true arteriovenous malformation: a rare entity among mixed vascular malformations of the brain. Case report. J Neurosurg. 1995 Jul;83(1):141–144. doi: 10.3171/jns.1995.83.1.0141. [DOI] [PubMed] [Google Scholar]
  26. Miyasaka Y., Kurata A., Tokiwa K., Tanaka R., Yada K., Ohwada T. Draining vein pressure increases and hemorrhage in patients with arteriovenous malformation. Stroke. 1994 Feb;25(2):504–507. doi: 10.1161/01.str.25.2.504. [DOI] [PubMed] [Google Scholar]
  27. Miyasaka Y., Yada K., Ohwada T., Kitahara T., Kurata A., Irikura K. An analysis of the venous drainage system as a factor in hemorrhage from arteriovenous malformations. J Neurosurg. 1992 Feb;76(2):239–243. doi: 10.3171/jns.1992.76.2.0239. [DOI] [PubMed] [Google Scholar]
  28. Morgan M. K., Johnston I. H., Hallinan J. M., Weber N. C. Complications of surgery for arteriovenous malformations of the brain. J Neurosurg. 1993 Feb;78(2):176–182. doi: 10.3171/jns.1993.78.2.0176. [DOI] [PubMed] [Google Scholar]
  29. Ogilvy C. S. Radiation therapy for arteriovenous malformations: a review. Neurosurgery. 1990 May;26(5):725–735. doi: 10.1097/00006123-199005000-00001. [DOI] [PubMed] [Google Scholar]
  30. Ondra S. L., Troupp H., George E. D., Schwab K. The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg. 1990 Sep;73(3):387–391. doi: 10.3171/jns.1990.73.3.0387. [DOI] [PubMed] [Google Scholar]
  31. Pasqualin A., Barone G., Cioffi F., Rosta L., Scienza R., Da Pian R. The relevance of anatomic and hemodynamic factors to a classification of cerebral arteriovenous malformations. Neurosurgery. 1991 Mar;28(3):370–379. doi: 10.1097/00006123-199103000-00006. [DOI] [PubMed] [Google Scholar]
  32. Pollock B. E., Lunsford L. D., Kondziolka D., Maitz A., Flickinger J. C. Patient outcomes after stereotactic radiosurgery for "operable" arteriovenous malformations. Neurosurgery. 1994 Jul;35(1):1–8. doi: 10.1227/00006123-199407000-00001. [DOI] [PubMed] [Google Scholar]
  33. Schaller C., Schramm J. Microsurgical results for small arteriovenous malformations accessible for radiosurgical or embolization treatment. Neurosurgery. 1997 Apr;40(4):664–674. doi: 10.1097/00006123-199704000-00003. [DOI] [PubMed] [Google Scholar]
  34. Schwartz M., O'Brien P., Davey P., Young C., Willinsky R., Catton C. Current status of radiosurgery for arteriovenous malformations. Can J Neurol Sci. 1991 Nov;18(4):499–502. doi: 10.1017/s0317167100032224. [DOI] [PubMed] [Google Scholar]
  35. Shi Y. Q., Chen X. C. A proposed scheme for grading intracranial arteriovenous malformations. J Neurosurg. 1986 Oct;65(4):484–489. doi: 10.3171/jns.1986.65.4.0484. [DOI] [PubMed] [Google Scholar]
  36. Sisti M. B., Kader A., Stein B. M. Microsurgery for 67 intracranial arteriovenous malformations less than 3 cm in diameter. J Neurosurg. 1993 Nov;79(5):653–660. doi: 10.3171/jns.1993.79.5.0653. [DOI] [PubMed] [Google Scholar]
  37. Solomon R. A., Stein B. M. Interhemispheric approach for the surgical removal of thalamocaudate arteriovenous malformations. J Neurosurg. 1987 Mar;66(3):345–351. doi: 10.3171/jns.1987.66.3.0345. [DOI] [PubMed] [Google Scholar]
  38. Solomon R. A., Stein B. M. Management of arteriovenous malformations of the brain stem. J Neurosurg. 1986 Jun;64(6):857–864. doi: 10.3171/jns.1986.64.6.0857. [DOI] [PubMed] [Google Scholar]
  39. Spetzler R. F., Martin N. A. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986 Oct;65(4):476–483. doi: 10.3171/jns.1986.65.4.0476. [DOI] [PubMed] [Google Scholar]
  40. Steinmeier R., Schramm J., Müller H. G., Fahlbusch R. Evaluation of prognostic factors in cerebral arteriovenous malformations. Neurosurgery. 1989 Feb;24(2):193–200. doi: 10.1227/00006123-198902000-00007. [DOI] [PubMed] [Google Scholar]
  41. Tew J. M., Jr, Lewis A. I., Reichert K. W. Management strategies and surgical techniques for deep-seated supratentorial arteriovenous malformations. Neurosurgery. 1995 Jun;36(6):1065–1072. doi: 10.1227/00006123-199506000-00001. [DOI] [PubMed] [Google Scholar]
  42. Wilson C. B., Hoi Sang U., Domingue J. Microsurgical treatment of intracranial vascular malformations. J Neurosurg. 1979 Oct;51(4):446–454. doi: 10.3171/jns.1979.51.4.0446. [DOI] [PubMed] [Google Scholar]
  43. Yamada S., Brauer F. S., Knierim D. S. Direct approach to arteriovenous malformations in functional areas of the cerebral hemisphere. J Neurosurg. 1990 Mar;72(3):418–425. doi: 10.3171/jns.1990.72.3.0418. [DOI] [PubMed] [Google Scholar]
  44. Yamamoto M., Jimbo M., Hara M., Saito I., Mori K. Gamma knife radiosurgery for arteriovenous malformations: long-term follow-up results focusing on complications occurring more than 5 years after irradiation. Neurosurgery. 1996 May;38(5):906–914. doi: 10.1097/00006123-199605000-00010. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Neurology, Neurosurgery, and Psychiatry are provided here courtesy of BMJ Publishing Group

RESOURCES