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

Marcel Alfter; Pablo Albiña-Palmarola; Alexandru Cimpoca; Roberto Díaz-Peregrino; Paul Jans; Oliver Ganslandt; Dietmar Kühne; Hans Henkes

doi:10.3390/jcm12185990

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 Sep 15;12(18):5990. doi: 10.3390/jcm12185990.

Authors

Marcel Alfter^{1

2}, Pablo Albiña-Palmarola^{1

2

3}, Alexandru Cimpoca¹, Roberto Díaz-Peregrino⁴, Paul Jans⁵, Oliver Ganslandt⁶, Dietmar Kühne⁷, Hans Henkes^{1

2}

Affiliations

¹ Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany.
² Medical Faculty, University Duisburg-Essen, 47057 Duisburg, Germany.
³ Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile.
⁴ Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, 69117 Heidelberg, Germany.
⁵ Clinic for Neurosurgery, Alfried Krupp Krankenhaus, 45131 Essen, Germany.
⁶ Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany.
⁷ Clinic for Radiology and Neuroradiology, Alfried Krupp Krankenhaus, 45131 Essen, Germany.

Abstract

Purpose: The treatment of high-grade brain AVMs is challenging and has no guidelines available to date. This study was aimed at reporting the experience of two centers in treating these AVMs through a multi-stage approach consisting of preoperative embolization and microsurgical resection.

Methods: A retrospective review was performed for 250 consecutive patients with a diagnosis of high-grade brain AVM (Spetzler-Martin grades III, IV, and V) treated in two centers in Germany between January 1989 and February 2023. The analyzed data included demographic, clinical, morphological, and neurological data.

Results: A total of 150 cases (60%) were classified as Spetzler-Martin grade III, 82 cases (32.8%) were classified as grade IV, and 18 cases (7.2%) were classified as grade V. Eighty-seven cases (34.8%) presented with hemorrhage. The devascularization percentages achieved were <50% in 24 (9.6%), 50-80% in 55 (22%), and >80% in 171 (68.4%) cases. The average number of sessions was 5.65 ± 5.50 and 1.11 ± 0.32 endovascular and surgical procedures, respectively, and did not significantly differ by rupture status. Death or dependency (mRS score ≥ 3) after the last follow-up was observed in 18.8% of patients and was significantly associated with age > 80 years and poor baseline neurological condition. The complete resection rate was 82.3% and was significantly associated with age > 80 years, large nidus, and deep venous drainage. Permanent disabling neurological deficit after at least 3 months of follow-up was diagnosed in 13.2% of patients and was significantly associated with age > 80 years and infratentorial locations.

Conclusion: A multi-stage treatment for high-grade AVMs is feasible for selected cases but comes at a functional cost. The devascularization percentage was not associated with the investigated outcomes. Age > 80 years was associated with poor safety and effectiveness outcomes; consequently, this treatment should be offered only in exceptional circumstances.

Keywords: arteriovenous malformation; embolization; microsurgical resection; multimodal treatment.

Grants and funding

This research received no external funding.