Seizure predictors and control after microsurgical resection of supratentorial arteriovenous malformations in 440 patients.
ABSTRACT Seizures are a common symptom of supratentorial arteriovenous malformations (AVMs), and uncontrolled epilepsy can considerably reduce patient quality of life. Potential risk factors for epilepsy in patients with AVMs are poorly understood, and the importance of achieving freedom from seizures in their surgical treatment remains underappreciated.
To characterize risks factors for preoperative seizures and factors associated with postoperative freedom from seizures in patients with surgically resected supratentorial AVMs.
We analyzed prospectively collected patient data for 440 patients who underwent microsurgical resection of supratentorial AVMs at our institution.
Among 440 patients with supratentorial AVMs, 130 (30%) experienced preoperative seizures, and 23 (18%) with seizures progressed to medically refractory epilepsy. Seizures were associated with a history of AVM hemorrhage (relative risk, 6.65; 95% confidence interval [CI], 3.81-11.6), male sex (relative risk, 2.07; 95% CI, 1.26-3.39), and frontotemporal lesion location (relative risk, 1.75; 95% CI, 1.05-2.93). After resection, 96% of patients had a modified Engel class I outcome, characterized by freedom from seizures (80%) or only 1 postoperative seizure (16%; mean follow-up, 20.7 ± 2.3 months). Comparable rates of postoperative seizures were seen in patients with (7%) or without (3%) preoperative seizures. AVMs with deep artery perforators were significantly associated with postoperative seizures (hazard ratio, 4.35; 95% CI, 1.61-11.7).
In the microsurgical treatment of supratentorial AVMs, hemorrhage, male sex, and frontotemporal location are associated with higher rates of preoperative seizures, whereas deep artery perforators are associated with postoperative seizures. Achieving freedom from seizure is an important goal that can be achieved in the surgical treatment of AVMs because epilepsy can significantly diminish patient quality of life.
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ABSTRACT: Children with brain arteriovenous malformations (BAVMs) are said to be at higher risk for intracranial hemorrhage (ICH) than adults. Although this notion affects treatment decisions, the evidence to support this claim is limited. To compare the risk of ICH in children versus adults with BAVM, we studied all cases of BAVM evaluated at the University of California, San Francisco (January 2000 to December 2004; n=400) and Kaiser Permanente Northern California (January 1993 to December 2004; n=819). In Kaplan-Meier survival analyses, the index date was the date of initial BAVM detection; cases were censored at time of subsequent ICH (the primary outcome, defined as ICH after initial presentation), first BAVM treatment, or loss to follow-up. Cox proportional hazards models included childhood presentation (<20 years old), hemorrhagic presentation, and other potential confounders. Our study included 996 person-years of follow-up in the childhood presentation group and 3260 in the adult presentation group. In the unadjusted survival analysis, the subsequent ICH rates were similar for the 2 age groups (average annual rate 2.0% for children; 2.2% for adults; P=0.82 by log-rank test). BAVMs in childhood were more likely to present initially with ICH (P<0.001). After adjustment for presentation in the multivariate model, subsequent ICH rates were lower in children (hazard ratio, 0.10; 95% CI, 0.01 to 0.86; P=0.036). Children with BAVMs do not appear to be at increased risk for a subsequent ICH compared with adults, and may even be relatively protected. Confounding by hemorrhagic presentation should be considered in any study comparing BAVM hemorrhage rates in children versus adults.Stroke 11/2005; 36(10):2099-104. · 6.16 Impact Factor
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ABSTRACT: The authors have updated a series of 166 prospectively followed unoperated symptomatic patients with arteriovenous malformations (AVM's) of the brain. Follow-up data were obtained for 160 (96%) of the original population, with a mean follow-up period of 23.7 years. The rate of major rebleeding was 4.0% per year, and the mortality rate was 1.0% per year. At follow-up review, 23% of the series were dead from AVM hemorrhage. The combined rate of major morbidity and mortality was 2.7% per year. These annual rates remained essentially constant over the entire period of the study. There was no difference in the incidence of rebleeding or death regardless of presentation with or without evidence of hemorrhage. The mean interval between initial presentation and subsequent hemorrhage was 7.7 years.Journal of Neurosurgery 10/1990; 73(3):387-91. · 3.15 Impact Factor
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ABSTRACT: Despite the great capacity for the pediatric brain to recover from stroke, the morbidity and mortality in children who harbor an arteriovenous malformation (AVM) remains high. This study examines the clinical data and management experience with 132 patients with brain AVM from 1949 to 1989. Although the high tendency for a childhood AVM to present with hemorrhage (79%) remained constant for the forty year study period, the associated morbidity and mortality of hemorrhage changed. The mortality rate from hemorrhage for the entire series was 25%, which was reduced from 39% to 16% after the introduction of computed tomography. The mortality from AVM hemorrhage since 1975 was dependent on location; 8 of 14 patients (57%) with a cerebellar AVM died from hemorrhage while only 2 of 44 patients (4.5%) with a cerebral hemisphere AVM died (p less than 0.0001). Sixteen children (12%) presented with a chronic seizure disorder. Surgical excision of the malformation resulted in complete seizure control off anti-convulsant medication in 73% of patients. Although 21% of patients were treated non-operatively (many with terminal poor-grade hemorrhage), 79% had a surgical procedure with total AVM excision achieved in 70 patients (53.1%). Complete AVM resection was followed by a normal neurological outcome in 47 children (67%). Most partial excisions (n = 9) and clipping of feeding arteries (n = 7) were performed in the early years of this study, and did not provide protection from rehemorrhage. Although conservative management has been advocated for selected non-hemorrhagic AVMs, we conclude that essentially all children with an AVM should be treated in order to eliminate the risk of hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 03/1992; 19(1):40-5. · 1.33 Impact Factor