Outcomes of Surgical Treatment of Patients with Cerebral AVM

N.N. Voznesenskaya, D.V. Svistov

Chair of Neurosurgery Medicomilitary Academy, Saint Petersburg, Russia

 

The goal f the present study was to estimate outcomes of surgical treatment of cases, operated for cerebral AVM.

Materials and Methods. There were 124 cases (89 males and 35 females) with cerebral AVM, operated in the Clinic of Neurosurgery of the Medicomilitary Academy. Retrospective analysis of results was carried out. A mean age was 33 years. Middle-sized (29%) and large (27.4%) AVM, localized in parietal (32.3%) and frontal (32.3%) lobes, were predominant. AVM of the I-II, III and IV-V type (Spetzler-Martin) were diagnosed in 26.6%, 36.3% and 37.1% respectively. Hemorrhagic and torpid types were watched in 51.6% and 48.4% respectively.

Operations consisted in unguided embolization in a flow (23 cases) and under conditions of a magnetic field (17 cases). Total exclusion of AVM from blood flow was achieved in 1 case only (2.5%). Superselective embolizaton of malformations with use of modern microcatheters, selective catheterization of feeders and glue compositions, based on fast-hardening acrylates, were performed in 61 cases. Total embolization of AVM was obtained in 31.2% of patients. Microsurgical interventions, aimed at AVM removal, were made in 23 cases. However, total extirpation was watched in 82.6% of patients.

Life quality was estimated on the basis of Mattis scale in all types of surgical treatment (I- unguided embolization, II - superselective embolization, III - microsurgical removal, IV - microsurgical removal after preceding embolization) before operation, on the 21 day after it and in 2 years. It was done after treatment completion in multi-stage interventions. Mattis index dynamics was compared with an initial life quality. We distinguished between normal or slightly reduced (the score of 108-144), moderately reduced (the score of 72-108), rather strongly reduced (the score of 36-72) and severely reduced (the score of less than 36) life quality.

Results. There was no reliable reduction of Mattis index in patients with unguided embolization and initially normal life quality (126.6±1.8; 111.4±2.4; 128.4±2.0). This index decreased reliably in cases with moderate reduction of life quality (75.3±3.2; 51.3±4.7; 62.6±6.6). Embolizaton inder conditions of a magnetic field did not change life quality irrespective of its initial state. Thus, unguided embolization has a negative effect on life quality. A combination of this fact with extremely low efficacy of intervention demands exclusion of these operations from a list of manipulation, used in cerebral AVM.

Superselective embolization had a favorable effect on life quality. It did not depend on its initial state and could be observed by the moment of discharge in spite of a considerable number of complications, which were transient in the majority of cases. Mattis index increased by 9-42. Its dynamics was more marked in patients with initially low life quality (increase by 32-124%) as compared with cases with high life quality before operation (increase by 7.5-8.3%).

Open surgical intervention effected life quality to a considerable extent. Mattis index grew by 20%, 24% and 9% in groups of patients with marked, moderate and normal life quality respectively. The highest life quality was watched in patients, operated after preliminary embolization (142.3±2.7).

Thus, the most positive dynamics of life quality was prone to cases, operated with use of superselective embolization. The highest mean values of Mattis index were observed after removal of AVM with its preceding embolization.

We analyzed life quality after radical embolization of AVM (19 cases), its microsurgical removal (19 cases), microsurgical removal with preceding embolization of AVM (7 cases). Mean values of Mattis index were as follows: 129.8±2.7; 108±6.4 and 142.3±2.7 respectively.

Conclusions

  1. All modern types of surgical interventions have a positive effect on life quality of patients with cerebral AVM. Unguided embolization has a negative effect on life quality and low efficacy. Embolization in a flow and magnetic field is to be excluded from neurosurgical interventions for cerebral AVM.
  2. Optimum results are achieved in microsurgical removal of preliminary embolized AVM, radical superselective embolization of AVM and its total microsurgical removal.
  3. Combined treatment of cerebral AVM ensures intervention efficacy and a high quality of life after operation.