sm grade v avm

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“What are the indications for surgical treatment in a 16-year-old patient presenting with ICH due to a SM Grade V AVM?”

EBS Meeting19/05/11Supervisor: Prof MK Morgan


• 16F / nil PMH • Long standing left sided tinnitus• Collapse – CTB -> Posterior fossa haemorrhage and early HCP.• PFD and Rt frontal EVD insertion.

What next?


Searchable question

P – pts with SM grade 5 AVMI – surgical interventionC – conservative management O – outcome (morbidity / mortality)


Searchable question

“What are the morbidity and mortality rates associated with resection of a SM grade V AVM? Do these justify surgical intervention? ”

Databases

• Medline – using MeSH

• Scopus using key articles and tracking citations


Medline• 68 articles.• 7 highly relevant.• Rest:

a)Not dealing with Intracranial AVM

b)Not dealing with surgery

c)Not in English


Scopus• Key articles searched by title and tracked their citations.• Further 5 articles identified.


Level of evidence

• Level 1: 0• Level 2: 0

• Level 3: The articles identified.


NHMRC level of evidence


• Prospective cohort• 631 consecutive patients with AVM • 1942- 2005• 63 pts with high – grade AVMs identified (Grade IV 50, Grade V 13 pts)• Mean f/u 11 years (1 month – 39.6 years)• 3 pts with Grade V presented with AVM rupture• Annual incidence of rupture: 3.3%• Cumulative rupture rates for recently ruptured high grade AVMs a)At 5 years: 21 – 58%b)At 20 years: 42 – 81%•Cumulative rupture rates for unruptured high grade AVMsa)At 5 years: 0 – 13%b)At 20 years: 3 – 46% •Previous rupture -> highly predictive of subsequent ruptures (6% per year)•Subsequent ruptures associated with higher risk of morbidity and mortality.


• Retrospective cohort• 73 consecutive patients – Grade IV (n=56) & V (n=17)AVMs• 1997 – 2000• No Tx in 55, Partial Tx in 7, Complete surgical Tx in 4• 14 pts – previous Tx, 59 pts no previous Tx• In total, 38 haemorrhages in 73 patients• Assumed AVM present since birth• Haemorrhage rate of 1.5% per year.• Indications for surgery: a)Several previous haemorrhages with significant neurological deficit


Chang SD et al. Multimodality treatment of giant intracranial arteriovenous malformations. Neurosurgery 53(1): 1-13, 2003

Preferable to focus on our results.


Andrew S Davidson & Michael K Morgan. How safe is arteriovenous malformation surgery? A prospective, observational study of surgery as first-line treatment for brain arteriovenous malformations. Neurosurgery 66(3): 498 – 505, 2010

• Prospective observational study• 20 years• 660 patients enrolled – SM Grade IV (n=7) & V (n=23)• 10 pts with SM Grade V AVM were operated. • Risk of adverse outcome due to surgery for this group (SM Grade V) is 24-76 % with 95% confidence interval.• Presence of deep perforating arterial supply -> asociated increased risk of surgical morbidity.


Conclusion

sm grade v avm

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