In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Risk of Hemorrhage in AVM Patients Over Age 60

    Final Number:
    210

    Authors:
    Wuyang Yang MD MS; Jose Luis Porras; Alice Hung; Tomas Garzon-Muvdi MD MS; Justin M. Caplan MD; Maria Braileanu BA; Joanna Wang BA; Geoffrey P. Colby MD, PhD; Alexander Lewis Coon MD; Rafael J. Tamargo MD; Judy Huang MD

    Study Design:
    Other

    Subject Category:
    Vascular Malformations

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: Treatment selection for patients=60 years with intracranial arteriovenous malformations(AVMs) requires careful consideration of natural history and post-treatment hemorrhagic risk. We aim to directly compare the natural history of AVMs with post-treatment hemorrhagic risk in patients=60 years.

    Methods: We retrospectively reviewed our institutional AVM database of 683 patients. Patients=60 years at diagnosis were included. Treatment modality was divided into 4 groups: surgeryembolization(SE), radiosurgeryembolization(RE), embolization only(EM), and observation(OB). Natural history of AVMs was defined as the annual risk of hemorrhage under observation. Risk of hemorrhage after treatment was also calculated.

    Results: Seventy-three patients(10.7%) satisfied inclusion criteria, and 61 patients with complete data were included. Average age was 68.47.5 years, with 55.7%(n=34) male. Spetzler-Martin grades were: grade I(n=14,23.0%), grade II(n=25,41.0%), grade III(n=17,27.9%), grade IV(n=4,6.6%), grade IV(n=1,1.6%). Twenty-seven(44.3%) patients presented with intracerebral hemorrhage(ICH). Treatment modality for all patients were: SE(n=11,18.0%), RE(n=16,26.2%), EM(n=2,3.3%), OB(n=32,52.5%). At last follow-up, average modified Rankin Scale(mRS) was similar between observed and treated patients(p=0.883). Overall obliteration rate is 65.5%, with 100.0% obliteration in SE and 43.8% in RE group(p<0.001). Four patients(12.5%) who underwent OB experienced spontaneous obliteration. During an average follow-up period of 2.83.2 years, five patients experienced hemorrhage, with 2(12.5%) in RE, 2(6.3%) in OB and 1(9.1%) in SE, corresponding to a natural history of 2.3% annual hemorrhage rate and a post-treatment hemorrhagic risk of 3.6%. This post-treatment hemorrhage risk was 2.4% in SE and 4.9% in RE group. One patient in SE experienced delayed angio-negative hemorrhage 13 years after AVM obliteration. Presentation with ICH was associated with a trend toward higher risk of follow-up hemorrhage(p=0.093).

    Conclusions: Definitive treatment for AVM patients=60 years should be considered cautiously. Although post-treatment obliteration rate is higher, the subsequent hemorrhagic risk may exceed that of its natural history. For AVMs deemed to be high risk for hemorrhage, surgical treatment achieves a higher rate of obliteration.

    Patient Care: Our current study demonstrates that for patients over the age of 60, a general conservative management should be considered given similar or even higher post-treatment risk. If definitive treatment must be initiated for patients deemed to be at high risk for subsequent hemorrhages, a surgical approach appears to be the optimal treatment modality. This study identifies the superior treatment strategy for a select cohort of patients, and helps to reduce unnecessary procedures that may expose patients to a greater risk of hemorrhage.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Understand that the natural history of AVM in patients over 60 years old is 2.3% 2) Understand that the post-treatment hemorrhagic risk is 3.6%, with SE being 2.4% and RE being 4.9% 3) By comparing these hemorrhagic risks, a more prudent selection of management strategy for this population should be considered in the context of AVM hemorrhage risk.

    References:

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy