Estimation of Treatment Benefit in Patients with Cerebral Arteriovenous Malformations
ABSTRACT
Background: Cerebral arteriovenous malformations (AVMs) are vascular lesions that may be associated with a significant morbidity and mortality. There is still today no consensus regarding treatment of unruptured AVMs. Using known data from the literature, and data from our own institution concerning stereotactic radiotherapy, our aim was to construct an equation that may be used to evaluate the benefit of intervention vs. conservative treatment in unruptured AVMs. Methods: Assuming an annual bleeding risk of 4% and previously reported mortality (29%) and morbidity (16%) rates after a bleeding from an AVM, an equation was constructed. This equation would estimate the time until the combined mortality and morbidity associated with conservative treatment would equal the mortality and morbidity of stereotactic radiotherapy. Results: Using stereotactic radiotherapy this treatment would benefit over conservative treatment in excess of 8.12 years. The risk of bleeding was the most important factor influencing the benefit of intervention vs. conservative treatment. Conclusions: We argue that that it may be possible to estimate the benefit of intervention vs. conservative treatment in an unruptured AVM. This may be achieved using our proposed equation and data specific to each center performing treatment for AVMs.
Background: Cerebral arteriovenous malformations (AVMs) are vascular lesions that may be associated with a significant morbidity and mortality. There is still today no consensus regarding treatment of unruptured AVMs. Using known data from the literature, and data from our own institution concerning stereotactic radiotherapy, our aim was to construct an equation that may be used to evaluate the benefit of intervention vs. conservative treatment in unruptured AVMs. Methods: Assuming an annual bleeding risk of 4% and previously reported mortality (29%) and morbidity (16%) rates after a bleeding from an AVM, an equation was constructed. This equation would estimate the time until the combined mortality and morbidity associated with conservative treatment would equal the mortality and morbidity of stereotactic radiotherapy. Results: Using stereotactic radiotherapy this treatment would benefit over conservative treatment in excess of 8.12 years. The risk of bleeding was the most important factor influencing the benefit of intervention vs. conservative treatment. Conclusions: We argue that that it may be possible to estimate the benefit of intervention vs. conservative treatment in an unruptured AVM. This may be achieved using our proposed equation and data specific to each center performing treatment for AVMs.
Cite this paper
P. Lindvall, P. Blomstedt and A. Bergenheim, "Estimation of Treatment Benefit in Patients with Cerebral Arteriovenous Malformations," Open Journal of Modern Neurosurgery, Vol. 2 No. 3, 2012, pp. 29-35. doi: 10.4236/ojmn.2012.23007.
P. Lindvall, P. Blomstedt and A. Bergenheim, "Estimation of Treatment Benefit in Patients with Cerebral Arteriovenous Malformations," Open Journal of Modern Neurosurgery, Vol. 2 No. 3, 2012, pp. 29-35. doi: 10.4236/ojmn.2012.23007.
References
[1] H. J. Svien and J. A. McRae, “Arteriovenous Anomalies of the Brain. Fate of patients not Having Definitive Surgery,” Journal of Neurosurgery, Vol. 23, No. 1, 1965, pp. 23-28. doi:10.3171/jns.1965.23.1.0023 [2] R. D. Brown, Jr., D. O. Wiebers, G. Forbes, et al., “The natural history of unruptured intracranial arteriovenous malformations,” Journal of Neurosurgery, Vol. 68, No. 3, 1988, pp. 352-357. doi:10.3171/jns.1988.68.3.0352 [3] S. L. Ondra, H. Troupp, E. D. George, et al., “The Natural History of Symptomatic Arteriovenous Malformations of the Brain: A 24-Year Follow-Up Assessment,” Journal of Neurosurgery, Vol. 73, No. 3, 1990, pp. 387-391. doi:10.3171/jns.1990.73.3.0387 [4] B. E. Pollock, J. C. Flickinger, L. D. Lunsford, et al., “Factors that Predict the Bleeding Risk of Cerebral Arteriovenous Malformations,” Stroke, Vol. 27, No. 1, 1996, pp. 1-6. doi:10.1161/01.STR.27.1.1 [5] J. A. Hernesniemi, R. Dashti, S. Juvela, et al., “Natural History of Brain Arteriovenous Malformations: A LongTerm Follow-Up Study of Risk of Hemorrhage in 238 Patients,” Neurosurgery, Vol. 63, No. 5, 2008, pp. 823831. doi:10.1227/01.NEU.0000330401.82582.5E [6] C. J. Wedderburn, J. van Beijnum, J. J. Bhattacharya, et al., “Outcome after Interventional or Conservative Management of Unruptured Brain Arteriovenous Malformations: A Prospective, Population-Based Cohort Study,” Lancet Neurology, Vol. 7, No. 3, 2008, pp. 223-230. doi:10.1016/S1474-4422(08)70026-7 [7] P. Lindvall, P. Bergstrom, M. Blomquist, et al., “Radiation Schedules in Relation to Obliteration and Complications in Hypofractionated Conformal Stereotactic Radiotherapy of Arteriovenous Malformations,” Stereotactic and Functional Neurosurgery, Vol. 88, No. 1, 2009, pp. 24-28. doi:10.1159/000260076 [8] D. Kondziolka, M. R. McLaughlin and J. R. Kestle, “Simple Risk Predictions for Arteriovenous Malformation Hemorrhage,” Neurosurgery, Vol. 37, No. 5, 1995, pp. 851-855. doi:10.1227/00006123-199511000-00001 [9] J. L. Pool, “Treatment of Arteriovenous Malformations of the Cerebral Hemispheres,” Journal of Neurosurgery, Vol. 19, No. 2, 1962, pp. 136-141. [10] J. H. Choi, H. Mast, R. R. Sciacca, et al., “Clinical Outcome after First and Recurrent Hemorrhage in Patients with Untreated Brain Arteriovenous Malformation,” Stroke, Vol. 37, No. 5, 2006, pp. 1243-1247. doi:10.1161/01.STR.0000217970.18319.7d [11] L. da Costa, M. C. Wallace, K. G. Ter Brugge, et al., “The Natural History and Predictive Features of Hemorrhage from Brain Arteriovenous Malformations,” Stroke, Vol. 40, No. 1, 2009, pp. 100-105. doi:10.1161/STROKEAHA.108.524678 [12] M. G. Hamilton and R. F. Spetzler, “The Prospective Application of a Grading System for Arteriovenous Malformations,” Neurosurgery, Vol. 34, No. 1, 1994, pp. 2-7. doi:10.1227/00006123-199401000-00002 [13] H. J. Pikus, M. L. Beach and R. E. Harbaugh, “Microsurgical Treatment of Arteriovenous Malformations: Analysis and Comparison with Stereotactic Radiosurgery,” Journal of Neurosurgery, Vol. 88, No. 4, 1998, pp. 641-646. doi:10.3171/jns.1998.88.4.0641 [14] G. Wikholm, C. Lundqvist and P. Svendsen, “Embolization of Cerebral Arteriovenous Malformations: Part I, Technique, Morphology, and Complications,” Neurosurgery, Vol. 39, No. 3, 1996, pp. 448-459. [15] V. Panagiotopoulos, E. Gizewski, S. Asgari, et al., “Embolization of Intracranial Arteriovenous Malformations with Ethylene-Vinyl Alcohol Copolymer (Onyx),” American Journal of Neuroradiology, Vol. 30, No. 1, 2009, pp. 99-106. doi:10.3174/ajnr.A1314 [16] M. V. Jayaraman, M. L. Marcellus, S. Hamilton, et al., “Neurologic Complications of Arteriovenous Malformation Embolization Using Liquid Embolic Agents,” American Journal of Neuroradiology, Vol. 29, No. 2, 2008, pp. 242-246. doi:10.3174/ajnr.A0793 [17] D. H. Pan, W. Y. Guo, W. Y. Chung, et al., “Gamma Knife Radiosurgery as a Single Treatment Modality for Large Cerebral Arteriovenous Malformations,” Journal of Neurosurgery, Vol. 93, No. 3, 2000, pp. 113-119. [18] W. A. Friedman, F. J. Bova and W. M. Mendenhall, “Linear Accelerator Radiosurgery for Arteriovenous Malformations: The Relationship of Size to Outcome,” Journal of Neurosurgery, Vol. 82, No. 2, 1995, pp. 180-189. doi:10.3171/jns.1995.82.2.0180 [19] E. Veznedaroglu, D. W. Andrews, R. P. Benitez, et al., “Fractionated Stereotactic Radiotherapy for the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization,” Neurosurgery, Vol. 55, No. 3, 2004, pp. 519-531. doi:10.1227/01.NEU.0000134285.41701.83
[1] H. J. Svien and J. A. McRae, “Arteriovenous Anomalies of the Brain. Fate of patients not Having Definitive Surgery,” Journal of Neurosurgery, Vol. 23, No. 1, 1965, pp. 23-28. doi:10.3171/jns.1965.23.1.0023 [2] R. D. Brown, Jr., D. O. Wiebers, G. Forbes, et al., “The natural history of unruptured intracranial arteriovenous malformations,” Journal of Neurosurgery, Vol. 68, No. 3, 1988, pp. 352-357. doi:10.3171/jns.1988.68.3.0352 [3] S. L. Ondra, H. Troupp, E. D. George, et al., “The Natural History of Symptomatic Arteriovenous Malformations of the Brain: A 24-Year Follow-Up Assessment,” Journal of Neurosurgery, Vol. 73, No. 3, 1990, pp. 387-391. doi:10.3171/jns.1990.73.3.0387 [4] B. E. Pollock, J. C. Flickinger, L. D. Lunsford, et al., “Factors that Predict the Bleeding Risk of Cerebral Arteriovenous Malformations,” Stroke, Vol. 27, No. 1, 1996, pp. 1-6. doi:10.1161/01.STR.27.1.1 [5] J. A. Hernesniemi, R. Dashti, S. Juvela, et al., “Natural History of Brain Arteriovenous Malformations: A LongTerm Follow-Up Study of Risk of Hemorrhage in 238 Patients,” Neurosurgery, Vol. 63, No. 5, 2008, pp. 823831. doi:10.1227/01.NEU.0000330401.82582.5E [6] C. J. Wedderburn, J. van Beijnum, J. J. Bhattacharya, et al., “Outcome after Interventional or Conservative Management of Unruptured Brain Arteriovenous Malformations: A Prospective, Population-Based Cohort Study,” Lancet Neurology, Vol. 7, No. 3, 2008, pp. 223-230. doi:10.1016/S1474-4422(08)70026-7 [7] P. Lindvall, P. Bergstrom, M. Blomquist, et al., “Radiation Schedules in Relation to Obliteration and Complications in Hypofractionated Conformal Stereotactic Radiotherapy of Arteriovenous Malformations,” Stereotactic and Functional Neurosurgery, Vol. 88, No. 1, 2009, pp. 24-28. doi:10.1159/000260076 [8] D. Kondziolka, M. R. McLaughlin and J. R. Kestle, “Simple Risk Predictions for Arteriovenous Malformation Hemorrhage,” Neurosurgery, Vol. 37, No. 5, 1995, pp. 851-855. doi:10.1227/00006123-199511000-00001 [9] J. L. Pool, “Treatment of Arteriovenous Malformations of the Cerebral Hemispheres,” Journal of Neurosurgery, Vol. 19, No. 2, 1962, pp. 136-141. [10] J. H. Choi, H. Mast, R. R. Sciacca, et al., “Clinical Outcome after First and Recurrent Hemorrhage in Patients with Untreated Brain Arteriovenous Malformation,” Stroke, Vol. 37, No. 5, 2006, pp. 1243-1247. doi:10.1161/01.STR.0000217970.18319.7d [11] L. da Costa, M. C. Wallace, K. G. Ter Brugge, et al., “The Natural History and Predictive Features of Hemorrhage from Brain Arteriovenous Malformations,” Stroke, Vol. 40, No. 1, 2009, pp. 100-105. doi:10.1161/STROKEAHA.108.524678 [12] M. G. Hamilton and R. F. Spetzler, “The Prospective Application of a Grading System for Arteriovenous Malformations,” Neurosurgery, Vol. 34, No. 1, 1994, pp. 2-7. doi:10.1227/00006123-199401000-00002 [13] H. J. Pikus, M. L. Beach and R. E. Harbaugh, “Microsurgical Treatment of Arteriovenous Malformations: Analysis and Comparison with Stereotactic Radiosurgery,” Journal of Neurosurgery, Vol. 88, No. 4, 1998, pp. 641-646. doi:10.3171/jns.1998.88.4.0641 [14] G. Wikholm, C. Lundqvist and P. Svendsen, “Embolization of Cerebral Arteriovenous Malformations: Part I, Technique, Morphology, and Complications,” Neurosurgery, Vol. 39, No. 3, 1996, pp. 448-459. [15] V. Panagiotopoulos, E. Gizewski, S. Asgari, et al., “Embolization of Intracranial Arteriovenous Malformations with Ethylene-Vinyl Alcohol Copolymer (Onyx),” American Journal of Neuroradiology, Vol. 30, No. 1, 2009, pp. 99-106. doi:10.3174/ajnr.A1314 [16] M. V. Jayaraman, M. L. Marcellus, S. Hamilton, et al., “Neurologic Complications of Arteriovenous Malformation Embolization Using Liquid Embolic Agents,” American Journal of Neuroradiology, Vol. 29, No. 2, 2008, pp. 242-246. doi:10.3174/ajnr.A0793 [17] D. H. Pan, W. Y. Guo, W. Y. Chung, et al., “Gamma Knife Radiosurgery as a Single Treatment Modality for Large Cerebral Arteriovenous Malformations,” Journal of Neurosurgery, Vol. 93, No. 3, 2000, pp. 113-119. [18] W. A. Friedman, F. J. Bova and W. M. Mendenhall, “Linear Accelerator Radiosurgery for Arteriovenous Malformations: The Relationship of Size to Outcome,” Journal of Neurosurgery, Vol. 82, No. 2, 1995, pp. 180-189. doi:10.3171/jns.1995.82.2.0180 [19] E. Veznedaroglu, D. W. Andrews, R. P. Benitez, et al., “Fractionated Stereotactic Radiotherapy for the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization,” Neurosurgery, Vol. 55, No. 3, 2004, pp. 519-531. doi:10.1227/01.NEU.0000134285.41701.83