Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience

Yu Chen, Ruinan Li, Li Ma, Xiangyu Meng, Debin Yan, Hao Wang, Xun Ye, Hengwei Jin, Youxiang Li, Dezhi Gao, Shibin Sun, Ali Liu, Shuo Wang, Xiaolin Chen, Yuanli Zhao, Yu Chen, Ruinan Li, Li Ma, Xiangyu Meng, Debin Yan, Hao Wang, Xun Ye, Hengwei Jin, Youxiang Li, Dezhi Gao, Shibin Sun, Ali Liu, Shuo Wang, Xiaolin Chen, Yuanli Zhao

Abstract

Objective: The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities.

Methods: The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017. The rupture risk was represented by annualised haemorrhagic rate. Patients were divided into five groups: conservation, microsurgery, embolisation, stereotactic radiosurgery (SRS) and embolisation+SRS. Neurofunctional outcomes were evaluated by the modified Rankin Scale (mRS). Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts.

Results: All of 61 brainstem AVMs (12 unruptured and 49 ruptured) were followed up for an average of 4.5 years. The natural annualised rupture risk was 7.3%, and the natural annualised reruptured risk in the ruptured cohort was 8.9%. 13 cases were conservative managed and 48 cases underwent intervention (including 6 microsurgery, 12 embolisation, 21 SRS and 9 embolisation+SRS). In the selection of interventional indication, diffuse nidus were often suggested conservative management (p=0.004) and nidus involving the midbrain were more likely to be recommended for intervention (p=0.034). The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management (p<0.001, p=0.036, respectively). In the subgroup analysis, the follow-up mRS scores of different management modalities were similar whether in the rupture cohort (p=0.064) or the unruptured cohort (p=0.391), as well as the haemorrhage-free survival (p=0.145). In the adjusted Bonferroni correction analysis of the ruptured cohort, microsurgery and SRS could significantly improve the obliteration rate compared with conservation (p<0.001, p=0.001, respectively) and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation (p=0.003, p=0.003, respectively).

Conclusions: Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts. If intervention is adopted, partial obliteration should be avoided because of the high subsequent rupture risk.

Trial registration number: NCT04136860.

Keywords: arteriovenous malformation; brain; intervention.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
The flow diagram of patient screening. AVM, arteriovenous malformation.
Figure 2
Figure 2
mRS scores of brainstem AVMs before and after conservation, microsurgery, embolisation, SRS and embolisation+SRS. AVM, arteriovenous malformation; mRS, modified Rankin Scale; SRS, stereotactic radiosurgery.
Figure 3
Figure 3
Kaplan-Meier plot. (A) Cumulative obliteration rates were similar between SRS group and embolisation+SRS group (p=0.439, log-rank test). (B) There was no significant difference in haemorrhage-free survival between different management modalities (p=0.145, log-rank test). SRS, stereotactic radiosurgery.

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