Delayed treatment of ruptured brain AVMs

Is it ok to wait?

Jeffrey S. Beecher, Kristopher Lyon, Vin Shen Ban, Awais Vance, Cameron M McDougall, Louis A. Whitworth, Jonathan A. White, Duke Samson, H. Hunt Batjer, Babu G. Welch

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

OBJECTIVE: Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS: Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS: Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS: It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

Original languageEnglish (US)
Pages (from-to)999-1005
Number of pages7
JournalJournal of Neurosurgery
Volume128
Issue number4
DOIs
StatePublished - Apr 1 2018
Externally publishedYes

Fingerprint

Arteriovenous Malformations
Brain
Therapeutics
Hemorrhage
Aneurysm
Rupture
Emergencies
Intracranial Aneurysm
Treatment Failure

Keywords

  • Arteriovenous malformation
  • Delayed surgery
  • Rehemorrhage risk
  • Vascular disorders

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Beecher, J. S., Lyon, K., Ban, V. S., Vance, A., McDougall, C. M., Whitworth, L. A., ... Welch, B. G. (2018). Delayed treatment of ruptured brain AVMs: Is it ok to wait? Journal of Neurosurgery, 128(4), 999-1005. https://doi.org/10.3171/2017.11.JNS16745

Delayed treatment of ruptured brain AVMs : Is it ok to wait? / Beecher, Jeffrey S.; Lyon, Kristopher; Ban, Vin Shen; Vance, Awais; McDougall, Cameron M; Whitworth, Louis A.; White, Jonathan A.; Samson, Duke; Batjer, H. Hunt; Welch, Babu G.

In: Journal of Neurosurgery, Vol. 128, No. 4, 01.04.2018, p. 999-1005.

Research output: Contribution to journalArticle

Beecher, JS, Lyon, K, Ban, VS, Vance, A, McDougall, CM, Whitworth, LA, White, JA, Samson, D, Batjer, HH & Welch, BG 2018, 'Delayed treatment of ruptured brain AVMs: Is it ok to wait?', Journal of Neurosurgery, vol. 128, no. 4, pp. 999-1005. https://doi.org/10.3171/2017.11.JNS16745
Beecher, Jeffrey S. ; Lyon, Kristopher ; Ban, Vin Shen ; Vance, Awais ; McDougall, Cameron M ; Whitworth, Louis A. ; White, Jonathan A. ; Samson, Duke ; Batjer, H. Hunt ; Welch, Babu G. / Delayed treatment of ruptured brain AVMs : Is it ok to wait?. In: Journal of Neurosurgery. 2018 ; Vol. 128, No. 4. pp. 999-1005.
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AU - Lyon, Kristopher

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AU - Vance, Awais

AU - McDougall, Cameron M

AU - Whitworth, Louis A.

AU - White, Jonathan A.

AU - Samson, Duke

AU - Batjer, H. Hunt

AU - Welch, Babu G.

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N2 - OBJECTIVE: Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS: Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS: Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS: It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.

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