title: Smoking is a negative predictor of arteriovenous malformation posttreatment obliteration: analysis of vascular risk factors in 774 patients.
abstract: OBJECTIVE
  Cigarette smoking has been well established as a risk factor in vascular pathology, such as cerebral aneurysms. However, tobacco's implications for patients with cerebral arteriovenous malformations (AVMs) are controversial. The object of this study was to identify predictors of AVM obliteration and risk factors for complications.
  
  
  METHODS
  The authors conducted a retrospective analysis of a prospectively maintained database for all patients with AVMs treated using surgical excision, staged endovascular embolization (with N-butyl-cyanoacrylate or Onyx), stereotactic radiosurgery (Gamma Knife or Linear Accelerator), or a combination thereof between 1994 and 2010. Medical risk factors, such as smoking, abuse of alcohol or intravenous recreational drugs, hypercholesterolemia, diabetes mellitus, hypertension, and coronary artery disease, were documented. A multivariate logistic regression analysis was conducted to detect predictors of periprocedural complications, obliteration, and posttreatment hemorrhage.
  
  
  RESULTS
  Of 774 patients treated at a single tertiary care cerebrovascular center, 35% initially presented with symptomatic hemorrhage and 57.6% achieved complete obliteration according to digital subtraction angiography (DSA) or MRI. In a multivariate analysis a negative smoking history (OR 1.9, p = 0.006) was a strong independent predictor of AVM obliteration. Of the patients with obliterated AVMs, 31.9% were smokers, whereas 45% were not (p = 0.05). Multivariate analysis of obliteration, after controlling for AVM size and location (eloquent vs noneloquent tissue), revealed that nonsmokers were more likely (0.082) to have obliterated AVMs through radiosurgery. Smoking was not predictive of treatment complications or posttreatment hemorrhage. Abuse of alcohol or intravenous recreational drugs, hypercholesterolemia, diabetes mellitus, and coronary artery disease had no discernible effect on AVM obliteration, periprocedural complications, or posttreatment hemorrhage.
  
  
  CONCLUSIONS
  Cerebral AVM patients with a history of smoking are significantly less likely than those without a smoking history to have complete AVM obliteration on follow-up DSA or MRI. Therefore, patients with AVMs should be strongly advised to quit smoking.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania.
authors.forename: Richard
authors.initials: R
authors.lastname: Dalyai
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Thana
authors.initials: T
authors.lastname: Theofanis
authors.forename: Christopher
authors.initials: C
authors.lastname: Busack
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.forename: L Fernando
authors.initials: LF
authors.lastname: Gonzalez
authors.forename: Robert
authors.initials: R
authors.lastname: Rosenwasser
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
mesh_terms: D000293:Adolescent; D000328:Adult; D001165:Arteriovenous Malformations / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D019106:Postoperative Hemorrhage / Q000453:epidemiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D016634:Radiosurgery / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D012907:Smoking / Q000453:epidemiology* / Q000523:psychology; D016896:Treatment Outcome; D055815:Young Adult
keywords: AVM = arteriovenous malformation; DSA = digital subtraction angiography; SM = Spetzler-Martin; SRS = stereotactic radiosurgery; arteriovenous malformation; hemorrhage; smoking