title: Comparative surgical outcome associated with the management of brain arteriovenous malformation in a regional neurosurgical centre.
abstract: OBJECTIVE
  Microsurgical resection of brain arteriovenous malformation (AVMs) is challenging, however, expert surgical series from large volume centres, have reported over 95% occlusion rates with 2 to 8% risk of morbidity & mortality. Data from a regional neurosurgical unit was analysed and compared with published series for the purposes of quality control. We also compared our surgical result with other treatment modalities from the whole AVM cohort managed over the same study period.
  
  
  METHODS
  Retrospective analysis of a locally held AVM database.
  
  
  METHODS
  Of the 141 AVM patients, 54 (35M, 19F, age range 9-68 years) underwent microsurgical removal of AVM by the senior author, from 2006 to 2012. 27 (19%), 18 (13%), 20 (14%), 22 (16%) had endovascular therapy only, radiosurgery only, combination therapy (endovascular and radiosurgery) and conservative management, respectively.
  
  
  METHODS
  Case notes were reviewed to determine clinical and radiological outcomes. Statistical analysis performed using SPSS with p < 0.05 defined as statistical significance.
  
  
  RESULTS
  In the surgical series, the Spetzler-Martin (SM) grade distribution was as follows: 17 grade I (32%), 31 grade II (57%), and 6 grade III (11%). 31 patients (57%) presented with intracranial haemorrhage, 12 patients (22%) with seizures. Of the 54 patients, 51 (94%) had angiographically confirmed obliteration of their AVM. Median follow-up for the entire cohort was 7 years. 83% of surgical patients have mRS 0-1, compared to 78%, 67%, 45%, 18% of patients managed by endovascular therapy, radiosurgery, combination therapy, conservative surveillance, respectively (p < 0.0001). However, the groups were not comparable in terms of SM grade or clinical presentation and the numbers in each group were relatively small. Seizure presentations were encountered in 23% (32/141) of the overall patients, and all the surviving patients were on anticonvulsants, except in the surgical arm, 7/12 (58%) patients were off their antiepileptic medications at last follow-up.
  
  
  CONCLUSIONS
  The results demonstrate a 94% surgical obliteration rate and 11% long-term neurological deficits for brain AVM patients managed surgically and were comparable to expert series. Achieving acceptable results is possible in lower volume settings, however, patient selection is important and the role of an experienced neurovascular team cannot be overstated.
authors.affiliation: a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK.
authors.forename: Mario K
authors.initials: MK
authors.lastname: Teo
authors.affiliation: a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK.
authors.forename: Adam M H
authors.initials: AM
authors.lastname: Young
authors.affiliation: a Department of Neurosurgery , Institute of Neurological Sciences, Southern General Hospital , Glasgow , UK.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: St George
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000927:Anticonvulsants / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000601:surgery*; D020300:Intracranial Hemorrhages / Q000209:etiology; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D016634:Radiosurgery / Q000379:methods; D012189:Retrospective Studies; D012640:Seizures / Q000188:drug therapy / Q000209:etiology; D016896:Treatment Outcome; D057832:Watchful Waiting; D055815:Young Adult
chemical_list: D000927:Anticonvulsants
keywords: Arteriovenous malformation; Lawton Young grade; Spetzler–Martin grade; literature review; microsurgical resection