Alfter Marcel, Albiña-Palmarola Pablo, Cimpoca Alexandru, Díaz-Peregrino Roberto, Jans Paul, Ganslandt Oliver, Kühne Dietmar, Henkes Hans
Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany.
Medical Faculty, University Duisburg-Essen, 47057 Duisburg, Germany.
J Clin Med. 2023 Sep 15;12(18):5990. doi: 10.3390/jcm12185990.
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.
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.
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.
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.
高级别脑动静脉畸形（AVM）的治疗具有挑战性，且目前尚无可用的指南。本研究旨在报告两个中心通过术前栓塞和显微手术切除的多阶段方法治疗这些AVM的经验。
对1989年1月至2023年2月期间在德国两个中心连续治疗的250例诊断为高级别脑AVM（Spetzler-Martin分级III、IV和V级）的患者进行回顾性分析。分析的数据包括人口统计学、临床、形态学和神经学数据。
共有150例（60%）被归类为Spetzler-Martin III级，82例（32.8%）为IV级，18例（7.2%）为V级。87例（34.8%）出现出血。血管减少百分比<50%的有24例（9.6%），50 - 80%的有55例（22%），>80%的有171例（68.4%）。血管内和外科手术的平均次数分别为5.65±5.50次和1.11±0.32次，且在破裂状态方面无显著差异。末次随访时死亡或依赖（改良Rankin量表评分≥3分）的患者占18.8%，且与年龄>80岁和基线神经功能状态差显著相关。完全切除率为82.3%，且与年龄>80岁、病灶大及深部静脉引流显著相关。至少随访3个月后诊断为永久性致残性神经功能缺损的患者占13.2%，且与年龄>80岁及幕下部位显著相关。
对于部分病例，高级别AVM的多阶段治疗是可行的，但会付出功能代价。血管减少百分比与所研究的结果无关。年龄>80岁与安全性和有效性结果差相关；因此，仅在特殊情况下才应提供这种治疗。
