title: Complication-Effectiveness Analysis for Brain Arteriovenous Malformation Surgery: A Prospective Cohort Study.
abstract: Intervention for brain arteriovenous malformations (bAVMs) should aim at treatment that is safe and effective.
  
  
  
  To analyze a prospective database to derive the probability of neurological deficit and adjust this risk for effectively treated bAVMs (complication-effectiveness analysis [CEA]).
  
  
  
  First, we calculated the percentage of surgical complications leading to a modified Rankin Scale >1 at 12 months after surgery for each Spetzler-Ponce class (SPC). Second, we performed a sensitivity analysis of these results by including bAVMs not undergoing surgery, to correct for bias. Third, we established the long-term cumulative incidence of freedom from recurrence from Kaplan-Meier analysis. Finally, we combined the results to calculate the risk of surgery per effective treatment in a complication-effectiveness analysis.
  
  
  
  Seven hundred seventy-nine patients underwent 641 microsurgical resections. Complications of surgery leading to a modified Rankin Scale >1 at 12 months occurred in 1.4% (95% confidence interval [CI]: 0.5-3.3), 20% (95% CI: 15-26), and 41% (95% CI: 30-52) of SPC A, SPC B, and SPC C, respectively. The cumulative 9-year freedom from recurrence was 97% for SPC A and 92% for other bAVMs. The 9-year CEA risk was 1.4% (credible range: 0.5%-3.4%) for SPC A, 22% to 24% (credible range: 16%-31%) for SPC B, and 45% to 63% (credible range: 33%-73%) for SPC C bAVM.
  
  
  
  CEA presents the treatment outcome in the context of efficacy and provides a basis for comparing outcomes from techniques with different times to elimination of the bAVM.
  
  
  
  bAVM, brain arteriovenous malformationCEA, complication-effectiveness analysisCI, confidence intervalCTA, computerized tomographic angiographyDSA, digital subtraction angiographyMRA, magnetic resonance angiographymRS, modified Rankin ScaleSMG, Spetzler-Martin gradeSPC, Spetzler-Ponce class.
authors.affiliation: *Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia; ‡Department of Statistics, Macquarie University, Sydney, New South Wales, Australia.
authors.forename: Michael Kerin
authors.initials: MK
authors.lastname: Morgan
authors.forename: Markus
authors.initials: M
authors.lastname: Wiedmann
authors.forename: Nazih N
authors.initials: NN
authors.lastname: Assaad
authors.forename: Gillian Z
authors.initials: GZ
authors.lastname: Heller
mesh_terms: D000328:Adult; D001921:Brain / Q000098:blood supply / Q000601:surgery*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008297:Male; D008866:Microsurgery / Q000009:adverse effects* / Q000379:methods; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome