title: A supplementary grading scale combining lesion-to-eloquence distance for predicting surgical outcomes of patients with brain arteriovenous malformations.
abstract: OBJECTIVE Case selection for the surgical treatment of brain arteriovenous malformations (BAVMs) remains challenging. This study aimed to construct a predictive grading system combining lesion-to-eloquence distance (LED) for selecting patients with BAVMs for surgery. METHODS Between September 2012 and September 2015, the authors retrospectively studied 201 consecutive patients with BAVMs. All patients had undergone preoperative functional MRI and diffusion tensor imaging (DTI), followed by resection. Both angioarchitectural factors and LED were analyzed with respect to the change between preoperative and final postoperative modified Rankin Scale (mRS) scores. LED refers to the distance between the lesion and the nearest eloquent area (eloquent cortex or eloquent fiber tracts) measured on preoperative fMRI and DTI. Based on logistic regression analysis, the authors constructed 3 new grading systems. The HDVL grading system includes the independent predictors of mRS change (hemorrhagic presentation, diffuseness, deep venous drainage, and LED). Full Score combines the variables in the Spetzler-Martin (S-M) grading system (nidus size, eloquence of adjacent brain, and venous drainage) and the HDVL. For the third grading system, the fS-M grading system, the authors added information regarding eloquent fiber tracts to the S-M grading system. The area under the receiver operating characteristic (ROC) curves was compared with those of the S-M grading system and the supplementary S-M grading system of Lawton et al. RESULTS LED was significantly correlated with a change in mRS score (p < 0.001). An LED of 4.95 mm was the cutoff point for the worsened mRS score. Hemorrhagic presentation, diffuseness, deep venous drainage, and LED were independent predictors of a change in mRS score. Predictive accuracy was highest for the HDVL grading system (area under the ROC curve 0.82), followed by the Full Score grading system (0.80), the fS-M grading system (0.79), the supplementary S-M grading system (0.76), and least for the S-M grading system (0.71). Predictive accuracy of the HDVL grading system was significantly better than that of the Spetzler-Martin grade (p = 0.040). CONCLUSIONS LED was a significant predictor for the preoperative risk evaluation for surgery. The HDVL system was a good predictor of neurological outcomes after BAVM surgery. Adding the consideration of the involvement of eloquent fiber tracts to preoperative evaluation can effectively improve its predictive accuracy.
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Yuming
authors.initials: Y
authors.lastname: Jiao
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Fuxin
authors.initials: F
authors.lastname: Lin
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Jun
authors.initials: J
authors.lastname: Wu
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Hao
authors.initials: H
authors.lastname: Li
authors.affiliation: 6Department of Neurosurgery, Hongqi Hospital, Mudanjiang Medical University, Mudanjiang, Heilongjiang, People's Republic ofChina.
authors.forename: Lijun
authors.initials: L
authors.lastname: Wang
authors.affiliation: 5Medical Imaging Center, 306th Hospital of the People's Liberation Army, Beijing; and.
authors.forename: Zhen
authors.initials: Z
authors.lastname: Jin
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Shuo
authors.initials: S
authors.lastname: Wang
authors.affiliation: 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.|2China National Clinical Research Center for Neurological Diseases.|3Center of Stroke, Beijing Institute for Brain Disorders.|4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease.
authors.forename: Yong
authors.initials: Y
authors.lastname: Cao
mesh_terms: D000293:Adolescent; D000328:Adult; D000465:Algorithms; D056324:Diffusion Tensor Imaging; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging* / Q000601:surgery*; D020300:Intracranial Hemorrhages / Q000000981:diagnostic imaging / Q000209:etiology; D008279:Magnetic Resonance Imaging; D008297:Male; D009434:Neural Pathways / Q000000981:diagnostic imaging; D059906:Neuroimaging / Q000379:methods*; D019635:Neurosurgical Procedures / Q000379:methods*; D011182:Postoperative Care; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: AF = arcuate fasciculus; AUC = area under the ROC curve; BAVM = brain arteriovenous malformation; BOLD = blood oxygen level–dependent; CST = cortical spinal tract; DSA = digital subtraction angiography; DTI = diffusion tensor imaging; DW = diffusion weighted; EPI = echo-planar imaging; Full Score = all variables in HDVL and S-M grading systems; HDVL = a grading system including hemorrhage, nidus diffuseness, deep venous drainage, and LED; HDVL grading system; LED = lesion-to-eloquence distance; ROC = receiver operating characteristic; ROI = region of interest; S-M = Spetzler-Martin; Spetzler-Martin grade; TOF = time-of-flight; brain arteriovenous malformation; fMRI = functional MRI; fS-M = S-M grading system with the addition of eloquent fiber tracts; lesion-to-eloquence distance; mRS = modified Rankin Scale; modified Rankin Scale; prediction grading systems; vascular disorders