10-year experience with staggered multimodal treatment in brain arteriovenous malformations in a single medical center in Mexico. An Observational Cohort Study

Abstract

Abstract An observational cohort study was performed in patients with diagnosis of brain AVM in a third level medical center in Mexico City, from December 2007 to January 2018. Patients were divided into 3 groups: small (S-M Grade I and II), Transitional (S-M Grade III) and Giant (S-M Grade IV and V). and then these groups subcategorized in bimodal treatment (embolization plus microsurgery) and others (microsurgery, radiosurgery, conservative). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups before treatment and 24 months follow-up. 97 patients were diagnosed, 22 excluded due to inconsistency in medical records or abandoning the treatment. The final sample analyzed was 75 patients. The overall had a mean age of 22 [14-38] years and the predominant sex was male in 55% (n=41). The clinical presentation was: focal neurological deficit 28% (n=21), seizures 27% (n=20), headache 24% (n=18), and intracranial hemorrhage 21% (n=16). Only seven (9.3%) patients from the total sample developed trans-procedural rupture of brain AVM, After 24 months follow up 24 (31.9%) patients remains with neurological sequel, and four (5.3%) died. In low grade brain AVMs the mean MRS decreased from 2.5±1.2 to 0.7±0.9, in transitional grade brain AVMs from 2.3±1.7 to 0.9±1, and in giant AVMs 2.4±1.1 to 2.3±2.1. Bimodal or multimodal treatment should be carefully considered in high-grade arteriovenous malformations. The main objective, having embolization as a first step is to reduce the risk of intraoperative bleeding, obliterating feeder arteries that will be difficult to control with microsurgery. Additionally, the risk of trans procedure rupture of the bAVM is directly proportional to the “aggressiveness” which it is treated.